Our first speaker today, or it would be all of them. My name is David Chang. I will be your moderator today. Pleased to introduce to you our first speaker. His name is Brock Blakewell. And so this is again, Research Spotlight for Pain and Spine Medicine. All right, you can go right over to the next slide for me. Well, good afternoon, everyone, or morning, depending on where you're joining us from. My name is Brock Bakewell, and I am currently serving as a research fellow at the Rothman Orthopedic Institute Foundation for Opioid Research and Education. And I will be presenting on the use of cannabidiol in patients with low back pain caused by lumbar spinal stenosis. Go ahead and go to the next slide. And so a little bit of background here. So I want to start off by first saying that we looked at cannabidiol or CBD. It is the second most prevalent compound in cannabis behind THC. So for those of you who are not familiar with cannabis at all, THC is the portion that is psychoactive and gives you that high feeling. So cannabidiol does not have that. And so it has been anecdotally looked at to be already a treatment for pain management. And so there is very little research surrounding CBD, but it has been shown to have some anxiolytic, anti-inflammatory, anti-emetic, and anti-psychotic effects. And so that's why we chose to look at this because as much of everyone really knows, especially here at pain management, is we don't want to kind of avoid that intoxicating effect of opioids and THC. So this is kind of a promising area. Now we looked at spinal stenosis, which is the degenerative narrowing of the spinal canal with encroachment on the neural structures by the surrounding bone and soft tissue. And we did this observationally because we were using a cannabis product. Go ahead and go to the next slide. So a little bit about our methods here. Our inclusion criteria was fairly simple. It was if a patient had that neurogenic cautication of radicular leg symptoms from spinal stenosis that was confirmed with the lumbar radiograph. Our exclusion criteria was anyone that had a spondylolisthesis or any prior spinal surgeries. So we looked at seven different surveys throughout a course of six visits. And each visit was about four weeks apart. And so at the end of each survey, we would then, or each visit after all the surveys were filled out, we gave them a coupon for the Onanda hemp CBD gel caps. And so these are a legal substance in the US under the 2018 Farm Bill, as long as they contain less than 0.3% THC. So that was kind of a good factor for us to include as well. Our surveys, we were mainly looking at a lot of pain, quality of life measures, and then we did have a cannabis familiarity or previous use survey as well to assess how familiar they were with the product or what we were prior knowledge. Ultimately, we ended up with 48 patients completing all six visits. And that was about 43% of the total that we enrolled. And we'll talk a little bit more about that in the discussion section when we get there, but a little bit lower retention than we would have liked. Our mean age was 75% or 75 years, and 67% of them were female. Go ahead and go to the next slide. So a little bit about our results. You can see our line graphs here in the top left, A, B, C, and D. So these were our pain variables mapped across the six variables. So A is pain right now, what that patient was feeling at the visit. B is the usual level of pain, which is across those retrospective four weeks that they had felt before, what was their average level of pain they felt? C being their best level of pain or whatever their level of pain was. D being their worst level of pain or whatever their lowest pain they felt, whatever they were in the least amount of pain across those four weeks, what was it? And then their worst level of pain, or D was the worst portion of it. And so when we have those, you can see that both B and D were both statistically significant. Now, they also saw a clinical significance of both a two-point reduction in their pain scores. We also saw that both of these pain scores were reduced with their other quality of life measures. So patients were standing less, they were eating more, they had an increased appetite, and they were changing positions less frequently. We also saw in this table, a little bit of sleep changes. Patients were sleeping more, they were waking up less, and they were falling asleep easier. We wanna be upfront with this that a lot of our evidence that we found, lots of THC-CBD combination medications have worked more effectively. And so even though we did see some of these quality of life measures increase, we want to ultimately use this as a stepping stone, maybe for some additional research, but anecdotally and through some of the literature, THC-CBD combination have been a more effective pain treatment. But ultimately going forward, this is one of the first studies of its kind. And so we really hope to continue on going forward with more double-blind control trial studies to see if this is an actual option to add into a clinical setting. I do wanna thank you again for looking at all of our research and attending the spotlight session. I will be on for the entirety of this session. So you can send me a direct message or wait for the Q&A session at the end. Thank you. Well done. Thank you so much. I think that's what we will ask the audience to do is if you have any questions for our speakers, kindly jot that down in the chat box and so we'll get to it at the very end. Our next speaker is Mr. Brody Fitzpatrick from University of Wisconsin. Thank you. So hi everybody. I'm Brody Fitzpatrick. I'm a fourth year medical student at the University of Wisconsin. I helped conduct this study with the help of doctors Poliak, Tunis, Miller and Cowling in the Department of Orthopedics and Rehabilitation. So overall the aim of our study was to evaluate the effect of genicular nerve radiofrequency ablation for knee osteoarthritis. Next slide, please. So overall, the background of this is that there's about 35 million people in the United States that have osteoarthritis and over half of them have, sorry, about 35 million people that are aged 65 and older, over half of them have about at least radiographic evidence of osteoarthritis in at least one joint. We know that for people with knee osteoarthritis, a total knee replacement can be a good treatment for them, but certain populations, particularly those with a BMI greater than 40 are often excluded from this treatment. Mostly because they have a higher surgical risk. So for these populations, as well as those people who don't want to go on to have surgery, two procedures, those being the genicular nerve block and the radiofrequency ablation have shown to improve outcomes in knee osteoarthritis by both reducing pain and improving function for anywhere up to about 12 months. Additionally, because osteoarthritis is such a prevalent disease that can cause debilitating symptoms, several management guidelines have been documented within the literature. However, despite that, the characteristic management of osteoarthritis within the general population is not always necessarily concordant with these recommendations. And so therefore, this is basically led to the development of some osteoarthritis management programs, which essentially serve to help patients with debilitating symptoms get high quality guideline-based care for their osteoarthritis. Now, however, these programs are generally new and the patient populations within them generally have more pain and dysfunction than you would generally see within the general osteoarthritis population. And so therefore these procedures, the genicular nerve block and radiofrequency ablation really haven't been studied within these populations. So we don't really know if they provide any additional benefit to these patients who do receive a high quality guideline-based osteoarthritis care. So essentially to address this question, what we did in our studies, we took 21 patients who were referred for these procedures from our osteoarthritis management clinic in Madison, Wisconsin, since we opened in October of 2017. Next slide. So of the 21 patients that we referred for a genicular nerve block, 18 ultimately went on to get a genicular nerve block and then five went on to get a radiofrequency ablation, totaling 26 blocks and seven ablations. And of those, the 18 patients were the only ones included within our statistical analyses. And we measured pain by doing a zero to 10 pain score, zero to 10 NRS scores at three time periods. One's immediately before and after the procedure while a patient was still in the hospital. And then once again, in a follow-up period, which had a meaning of about 45 days. In addition to pain scores, we took some osteoarthritis indices, including the VR-12, the KUS score and the WOMAC, as well as some physical function tests, those being the timed up and go, the single leg stance and the chair rise. And overall, what we found is that both in the post-operative and follow-up periods for both the genicular nerve block and radiofrequency ablation, they provided adequate significant pain relief for our patients. And although it wasn't completely significant, it was trending where in the post-operative period, we found this trending interaction wherein the genicular nerve block actually provided about 23% greater pain relief than did the radiofrequency ablation. And then lastly, we did find a significant correlation in the follow-up period wherein the WOMAC scores were correlated with pain scores, wherein higher WOMAC scores led to more pain relief in the follow-up period. Next slide. So some interesting points from this study. The first of which is that what we found in the trending interaction wherein the block, the genicular nerve block provided more pain relief in that post-operative period than did the radiofrequency ablation. And that's interesting because you would expect a complete nerve block to, or ablation to provide more pain relief than a transient block might. And all that's interesting, it's actually been documented in the past. And one of the thought processes behind that is, is that there's some sort of incongruence in the area anesthetized by the lidocaine that's not subsequently ablated during their radiofrequency ablation. And if you think about it, that kind of makes sense. When you do a block, you kind of put this viscous solution into the area of the knee that allows it to kind of percolate out and cover more of those fine sensory nerve endings. Whereas in an ablation, the area of nerve destruction is essentially limited to the area that's immediately around the probe. Additionally, we do this under fluoroscopic guidance. So we're not using direct visualization. We're just using bony landmarks to put the probe in the area where that we believe that the nerve should be approximately. But if there are sort of anatomic variations in where the nerve is, as well as where we place the electrode, you can get an incomplete neurotomy. Secondly, we didn't really find any relationship between pain scores and BMI, which is interesting because it contradicts two prior studies that do demonstrate an association between increased BMI as well as increased likelihood of knee pain, which is also what we would expect. We would expect patients with higher BMIs to have higher axial loads on their knees. And especially for patients with knee osteoarthritis, we expect them to have more pain. The caveat to that in our particular study is that we ran this study out of an osteoarthritis management program, which is essentially by definition means we had patients with worse pain and worse dysfunction that needed an osteoarthritis management program. And also they usually were non-surgical. They all were non-surgical candidates, but usually because their BMI was too high, which means usually they were above 40. And if you look at our patient population, all but three of our patients had a BMI equal to or greater than 32.5. So essentially it's possible that at some level of a BMI with enough severe symptoms of debilitation that it really doesn't fluctuate that much with an increase in BMI, whereas you might see kind of that interaction with healthier or even overweight BMIs perhaps. And then lastly, one of our goals in this study was to identify variables that would be successful in predicting which of our patients are gonna do well with these procedures. And we did find that there was a correlation between patients who had higher WOMAC scores, meaning they had higher, worse pain, worse dysfunction, had a higher likelihood of benefiting from these procedures. Now we were limited in our study a little bit by our smaller sample sizes, but should this kind of trend hold true in the future, it would be helpful in using something like the WOMAC score in identifying patient selection processes and referral processes to go for these procedures. But overall, in our study, we did find that the genicular nerve block and radiofrequency ablation did in fact provide significant pain relief for patients with osteoarthritic knee pain, particularly those who have more debilitating symptoms that required an osteoarthritis management program. And in addition to receiving all of that high quality guideline-based care that they could get in those clinics. And additionally, in the future, perhaps the WOMAC may be helpful in identifying candidates to help guide our patient selection and referral processes for these procedures. Next slide. I just wanna thank everybody for having me and I'll be available at the end if anyone has any questions. Thank you for that. Looks like there are a lot of questions waiting for you. Our next speaker is Dr. Timothy Oliver. And so he'll be speaking about clinical practice guidelines and interventional treatment of low back pain. All right, you should be good. Okay, next slide. For those of you who don't know me, Tim Oliver again, I'm a second year resident in PM&R at UT Southwestern and I'll be presenting our study today, quality of clinical practice guidelines on the interventional treatment of low back pain. Next slide. Perfect. So it's certainly no secret that chronic low back pain is a highly prevalent medical condition with a very high societal burden, both in terms of dysfunction, disability, direct financial cost of the healthcare system in general, both in the United States and around the world certainly. In terms of the interventional treatment of low back pain, it's an area of medicine that's expanded rapidly, especially over the last few decades. And there's also been a fair amount of variability in use of these techniques as well. There was a study back in 2012 that had noted that the top 10% of utilizers of these techniques performed about four and a half times as many procedures as the average interventional provider, at least at that time. So, given the prevalence of this condition, given how quickly the interventional treatment of low back pain has grown in the last few decades and given the variability and the use of these techniques, staying up to date on the available evidence is very important. A great tool used to this effect are clinical practice guidelines, which are used to organize the available evidence used commonly throughout medicine, throughout all subspecialties and specialties. And they do a very good job of facilitating the translation of research into clinical practice through a systematic and comparative review of the available evidence. And though these are very good tools, there is a lot of variability within clinical practice guidelines themselves. So, a tool kind of used to the effect of evaluation there is the appraisal of guidelines for research and evaluation to more easily described as the Agree 2 tool. And this is a tool that's used to systematically appraise the variability in clinical practice guideline development and quality. And the goal of this tool being to identify the best quality clinical practice guidelines so that the evidence and recommendations from those can be adopted. The objective of our specific study was to assess the quality of clinical practice guidelines specifically on the interventional treatment of chronic low back pain. The design was a systematic third-order umbrella review of clinical practice guidelines and an appraisal using the Agree 2 tool. In terms of the setting, the clinical practice guidelines came from all over the world. Countries included the United States, the United Kingdom, Denmark, the European Union, Canada, Belgium, South Korea, the Netherlands, Saudi Arabia, Australia, and Russia. And the clinical practice guidelines were created by a variety of government and professional society organizations. Next slide, please. Thank you. So our initial search of multiple databases yielded 714 documents with a specific set of inclusion and exclusion criteria. This was then vetted to 79 full texts, which were then screened to 21 final appraised clinical practice guidelines after review of the full texts. They were then all assessed, appraised by the Agree 2 tool. And the Agree 2 tool, you can see on the right side of the screen, assesses six domains and 23 items. So the six domains assessed were scope and purpose, stakeholders, rigor of development, clarity of presentation, applicability, and editorial independence. And these were all assessed on a seven-point Likert scale that you can see at the bottom. One being strongly disagree and seven being strongly agree. So an example of one you might go through is domain one, item one, where it's the overall objectives of the guideline are specifically described. So you would read through the clinical practice guideline. You would then read through that item and assess based on the seven-point scale where you thought that clinical practice guideline lined up for that item and assigned it a number one through seven. And you would then do that for all 23 items. For each of the 21 clinical practice guidelines, there were a total of four appraisers. There were six appraisers in total for our study. So each of them evaluated 14 clinical practice guidelines. In terms of final outcome measures, so there was a score given for each item. These were then gathered to give percent scores for each domain for each clinical practice guideline. There was also an overall quality score given to each clinical practice guideline. And that was also one through seven. There was also an overall recommendation given. So this was whether they would recommend use of this clinical practice guideline or not. So this was either yes, yes with modification or no. And we also calculated inter-rater reliability as well. Next slide, please. So in terms of our results for the 21 appraised clinical practice guidelines, you can see the overall quality score range at the right side of the screen. So the range was from 2.5 to 6.75, again, on a one to seven scale with the average of all overall quality scores being 5.2. For domain scores, the lowest score was for applicability at 44% of available points. And the highest average percent score for all clinical practice guidelines was for clarity of presentation at 82%. In terms of overall recommendation, yes, yes with modification or no. Six clinical practice guidelines only received yes votes. Five received at least one no vote and two received only no votes. And the inter-rater reliability was excellent. The p-value was less than 0.001. So in conclusion, for our assessed 21 clinical practice guidelines that were assessed, there was a fair amount of variability, though the majority were recommended for clinical use. Therefore, we do recommend scrutiny before recommendations are adopted, but again, stress that overall, most were recommended for clinical use and the overall quality was on the higher side as well. In terms of the domain scores themselves, there's certainly area for focus in the future, such as with applicability, which had scored the lowest of all domains. So that's an area for future developers of clinical practice guidelines to be aware of an area to focus on. So that concludes this presentation. Thank you all for your time. Thank you, Dr. Oliver. Our next speaker is Jeremy Holden. He'll be speaking to us about race-specific differences and outcome measures for chronic low back pain. Thank you for the introduction. So my name is Jeremy Holden and I'm a third year medical student at the Texas College of Osteopathic Medicine. And as he said, I'm here to present my research, which I worked on with Dr. Nicole Phillips at my home institution, the University of North Texas Health Science Center. Next slide, please. So our study looks at the serotonin receptor gene 5-hydroxytryptamine 2A, or HTR2A, and how haplotypes may be related to population-specific self-reported ratings of pain intensity, disability, and overall mental response in regards to their chronic low back pain. So this receptor is the main excitatory subtype of serotonin receptor with some single nucleotide polymorphisms found in high frequencies among chronic neuropathic pain patients, but we've also seen it related to psychiatric conditions. So it may be involved in both descending inhibitory pathways related to pain itself, but also the psychiatric disorders showing varying relationships with the pathologies themselves and response to different treatments. So with our knowledge of the top-down modulation of pain, there may be some evidence to suggest a relationship between psychology and reactions to nociceptive stimuli. So variations of our gene may therefore influence perceived severity of chronic low back pain and coping ability. Next slide, please. So for our methods, first of all, on the top left, you can see that we constructed our haploblocks from our gene. We chose SNPs based on their population frequency, availability on our specific sequencing chip, and any literature documenting relationship to any psychological or pain outcomes. So you can see that we looked at all our SNPs we chose, looked at which ones were in linkage dyseucal or bin with each other, and we constructed two haploblocks, A and B. Patients for the study came from our National Pain Registry, the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation Precision, which was spearheaded at our institution. So we received survey information and the genetic samples as well. So this study had two analyses. So the first one was the race-specific haplotype analysis, which you can see in detail in the bottom left. So we divided our entire population into black and white populations, and within those populations, a analysis was run for each type of haploblock. So we're comparing different haplotypes within the haploblock using Kruskal-Wallis tests and then subsequent pairwise comparisons. And we use the following validated measures. So we use the Roland-Morris Disability Numerical Rating Scale, SPADE score, which was for sleep disturbance, pain interference with activities, anxiety, depression, and low energy, which is just a overall kind of judgment of their quality of life. And we also use pain catastrophizing, kind of how exaggerated a patient's pain perception tends to be, and self-efficacy, so how much a patient feels like they can modify or overcome their painful stimuli. In our second half of the analysis, we looked at overrepresented alleles. So haplotype frequencies that showed overrepresentation in one racial group versus the other were noted and listed in the bottom right chart on the right. So for each analysis, the entire population was divided based on whether they had at least one copy of the allele of focus, and then t-tests and subsequent regressions were used to compare groups for the same outcome variables detailed earlier. Next slide, please. So in terms of results, in the top left, I've detailed which haploblocks and haplotypes were used, and they're numbered based on the racial category. So in haploblock A for the black subgroup, there are differences in the distributions of patients' RMDQ, catastrophizing, and self-efficacy. And when we ran pairwise comparisons, we found that VA4 trended with a lower catastrophizing and higher self-efficacy than the other groups in its category. In haploblock B for the white subgroup, distributions differed in Roland Morris and then self-efficacy. So when we looked at pairwise comparisons, we saw that WB4 trended with a lower RMDQ and higher self-efficacy than all of the other groups. On the right side, you can see that we have a bar graph that details significant differences in groups according to outcome variables. And this is for the overrepresented allele analysis. So we're looking at whether they had at least one of the alleles of focus. So what we found was that the GC allele was associated with a lower NRS and a lower catastrophizing score overall, even after multivariate regressions. So when we look at VA4 specifically, we saw that it had a trend of lower catastrophizing and higher self-efficacy. So this is kind of better coping strategies for the patient. So an A allele on RS6313, which is one of the SNPs we used, has been found with high levels of disability and pain sensation, while a G allele has been seen in patients with increased suicidal ideation and psychiatric conditions. So we have a mix of the two in this specific haplotype, which serves as an interesting phenotype, and we aren't really sure about what kind of possible interaction they may have. An A allele for RS9567746 has been associated with decreased somatic symptoms. And then likewise, an A allele for RS1928040 may have some role in earlier response to antidepressants. So the specific combination of SNPs may interact with each other or other factors to produce this overall phenotype. For haplotype WB4, which is a homozygous GC allele, we found that that was associated with a lower RMDQ and higher self-efficacy. So the G allele has been seen in patients with an earlier response to antidepressants, while a C allele may decrease chances of post-surgical pain according to some of the studies we looked at. The results of this study may therefore support some kind of literature that this GC haplotype may confer some kind of psychological or physical protective effect. So all in all, the study's power is limited by some of the lower populations of some haplotype groups, but regardless, this study provides some kind of context that HTR2A may be implicated in population-specific risk and manifestation of chronic low back pain. I want to thank you all for listening, and then I'll be available for questions afterwards. Thank you so much. And with that, we will turn to our last presentation. And so this is Melissa Pufenich from UCLA. She'll be talking to us about the role of EMG in patients undergoing cervical epidural steroid injections. Thank you. Yeah, my name is Melissa Pufenich. I worked on this study with my co-residents, Dr. Sheehan and Dr. Percy, and our PIs, Dr. Oshiro and Dr. Nastassi. So the title is the role of electromyography in patients undergoing cervical epidural steroid injections. To give you a little bit of background, the role that EMG plays in diagnostic confirmation of radiculopathy is well-established in the literature. However, not much research exists regarding its role in predicting outcomes after cervical epidural steroid injections for cervical radiculopathies. So the objective of our study was to determine if EMG confirmation of cervical radiculopathy can predict a positive treatment outcome following epidural steroid injection. The design of our study was a retrospective chart review study. Our participants were veterans who received cervical epidurals between 2010 and 2020. And our primary outcome is the percentage of pain reduction two weeks after cervical epidural injection. We had about 70 participants and we categorized these participants into three different groups. So those who had EMGs that confirmed cervical radiculopathy, those who had EMGs, but they did not confirm cervical radiculopathy. And then the third group did not have any EMG prior to the injection. To make it uniform, we defined EMG pop confirmed cervical radiculopathy as the EMG had to show at least two muscle abnormalities in the same myotome with different peripheral nerve distributions on a six muscle screen showing neuropathic changes. Once we broke these participants into three groups, we then categorized them as responders or non-responders after their cervical epidural steroid injection. We defined responders as those participants who had at least 50% pain reduction after the epidural and non-responders, they were considered non-responders if they had less than 50% pain reduction. And then so for our results, the main graph in the middle. So the EMG positive group on the left is the EMG confirmed group. The middle one is the ones who had EMG, but it did not confirm cervical radic. And then the last group EMG zero is the ones who did not have any EMG at all. And then the yellow part is those who had at least 50% pain relief. So responders. And then the pink part is those who weren't considered non-responders with less than 50% pain relief. So you can see that our EMG confirmed for cervical radiculopathy had the most significant relief. And then on the top right, we did an analysis of each group, comparisons between each group. And we found that patients with EMG confirmed cervical radiculopathy were greater than five times more likely to be responders after cervical epidural compared to patients without EMG confirmation for cervical radiculopathy. And then we did not find any statistical significance between the group that had EMG confirmed cervical radiculopathy compared to those who did not have any EMG. And I hypothesize that that could be because the people who did not require any EMG were more of a clinical textbook diagnosis for cervical radiculopathy. We think that this data and study could be very significant because the VA is the largest national healthcare system in the U.S. And examining the utility of the diagnostic workup for veterans receiving cervical epidural steroid injections and determining which patients are most likely to benefit from these epidurals is essential for both veterans' health and managing healthcare expenditures. Think that this could help guide clinical decision-making by reducing the risk of undergoing an unnecessary invasive procedure. And also by eliminating any unnecessary procedures, we minimize any unneeded face-to-face contact and potential COVID-19 transmissibility. The limitation of this study is that it was done at the VA, so this data or these results may not be applicable to the general population, the non-veteran population. In the future, studies could be done, obviously, on non-veteran populations. But we have also, on all these participants, collected secondary data that could be analyzed. So we have age, gender, race, BMI, if they've had a positive butox, if they have used opiates, if they have any psychiatric comorbidities, if they have any service connection, all of their MRI findings. We have also all collected that data that we could analyze as potential correlates or predictors of pain response after cervical epidural steroid injection in our future studies. And thank you for listening. Great, thank you so much. I am going to now invite all of the faculty members to be present on the screen, and we'll go over some questions that are in the chat box. The very first question is for our last presenter. Yeah, the question states, what was considered a positive EMG confirmation for active degeneration or polyphasic potentials? Can you speak to us a little bit about that, please? Sorry, can you repeat the question? Sure, the question was, what was considered a positive EMG for reticulopathy? Oh, sorry. So we defined EMG positive if they had at least two muscle abnormalities in the same myotome with different peripheral nerve distributions on a six-muscle screen showing neuropathic changes. So I think the question is asking what type of changes on EMG specifically, what do they have to be, active findings or chronic findings? So for this particular analysis, we included active and chronic, but we in the future do have the ability to sort it out as acute versus chronic to see if there's a difference, but we did not do that analysis for these results. Perfect. And so just as a piggyback question for me is, what do you foresee the clinical implications of EMG in patients who have cervical reticular pain? So based off of this study, we found that they had better outcomes if the cervical reticulopathy was confirmed on EMG, so potential predictor, but also that group compared to the group who just had no EMG, there wasn't as statistically significant as a difference. So I think if a patient came in and they were just a classic textbook diagnosis, EMG still might not be necessary, but if you're unsure, then an EMG could probably benefit the patient. That's a great answer. The second question is for Brody Fitzpatrick, and the question states for genicular block or RF, any comments on progression of osteoarthritis for average time to total knee replacements being increased or decreased? Yeah, I think that's a good question. I think it's harder for us to answer because I think most studies around genicular nerve blocks and radiofrequency ablations are generally smaller studies that aren't very longitudinal. So it's hard for us to tell, does it limit progression of osteoarthritis or their time to get to a total knee replacement? I would say probably anecdotally, we would say that that's true because people tend to get pain relief for anywhere up to a year from these procedures, and that then prevents them usually from going to get a knee replacement because usually the reason people get a knee replacement is that they have severe pain, even if they have a very poor looking X-ray, but they don't have any pain, they usually don't care to go on to get a knee replacement. But if they have severe pain, they usually are pushing for it. But usually in these patients, if we provide them significant pain relief, they're a little bit more hesitant to go on and subsequently get a knee replacement. So I would say anecdotally, we would say, yeah, it probably does prolong their average time to a total knee replacement. But I don't know that from the data perspective that we would be able to concretely answer that question. Okay. Actually, a lot of the questions in the chat have already been answered. So I am at this time going to open up to the audience to come join us and to ask our presenters and faculty questions. Okay, while we're waiting for questions, I have some questions. My question is for Brock Bakewell, and I am interested in whether there was a functional improvement besides the pain relief that you cited, and secondarily, was there a control for coexisting treatments besides CBD? So for the first question, through our results, the functional was basically just all of our quality of life measurements, and we had them assess a lot of different things retrospectively, each visit, you know, how were the first, you know, previous four weeks for that? And so throughout the study, they did, you know, confirm or they, there was some statistical significance of improvement in, patients were reporting they were able to stand longer, they were not moving around as much, they weren't changing positions as frequently due to those lower pain scores, but there wasn't any actual measurement for functional recovery. And then as for the second portion of your question, could you repeat that for me? The question was, was there a control for coexisting treatments? Okay, yeah, the only thing that we screened out were previous surgeries. So if they had any sort of spinal surgery, that was basically, they were excluded from our study, but any other treatment that they had, so if they were currently in physical therapy or they were getting steroid injections, this was an added therapy. And so this improvement could have been overshadowed by that because we did not control for what they were seeking outside of our study. Great, thank you. We have another question for EMG and cervical ESI. The question is, the EMG zero group, did they have a nerve conduction study done also? We actually didn't look to see if they had, or if they may have had nerve conduction study, but we didn't, we just considered it EMG, them to be in the EMG zero group or whatever group they would be in according, we only looked at if they had an EMG, not nerve conduction studies. So they may have had one, but we didn't look at that. Great. The next question comes to us from Dr. Kroll. And so for the study looking at racial differences in 5-HT and chronic low back pain, how was this determined? Was this through self-identification? So this was actually through self-identification. So in the beginning, we sent out a giant packet to all of our participants that kind of had all of the demographics and also some other kind of outcome variables. So it was all self-reported. And we kind of limited it to black and white patients just because other racial groups were very, like not represented among our overall population. Okay. And I'm still waiting for questions to come in. Do you have questions for each other? Okay. Okay, no. All right. Well, Jeremy, I am really intrigued by your research project. And how do you foresee that this research will affect clinical practice? We're mostly aiming, so we know that depression is a really common comorbidity with chronic pain. And we know that there's some kind of interplay between like mental health and then like just the overall pain experience. So I think kind of looking at that and seeing like different genetic factors that maybe influence a person's psychological status and how they're personally handling that pain, kind of treating that with whatever kind of drug or kind of counseling, just kind of considering everything as like a holistic approach to actually combating their chronic low back pain. Because sometimes there's no, you don't see a pathology. Sometimes it's more mental for that patient. Great. Well, I think that wraps it up for us. I want to thank our faculty members for sharing their research with us. I want to thank the audience for joining us. And lastly, I want to thank the Academy staff members for helping us run this presentation smoothly. Thank you so much. Have a wonderful day. Thank you.

cannabidiol

low back pain

genicular nerve radiofrequency ablation

knee osteoarthritis

clinical practice guidelines

EMG

cervical epidural steroid injections

pain management