Hello, everyone. Thank you for joining us in the session 1904, the Research Spotlight Pain and Spine Medicine. Today, we have seven authors who will present their research that has been culled from over 700 submissions this year and has been reviewed by our peer review process. And we're going to start today with Terrence Hillary, who's a fellow at Case Western Metro Health. Do muscle relaxants decrease total opioid use after lumbar spine surgery? A retrospective analysis. Dr. Hillary. Hi, thank you for having me and thank you for the introduction. As was just said, I was one of the co-authors on this study. Do muscle relaxants decrease total opioid use after lumbar spine surgery? A retrospective analysis. I'll start with some background. Recent clinical practice guidelines from societies in several medical specialties support the short-term use of skeletal muscle relaxant medications for acute low back pain. Really, the remaining points of contention are whether the therapeutic effect is independent of the sedative effect and around the tolerability of that and other adverse effects from skeletal muscle relaxants. As focus is sharpened on perioperative outcomes, clinicians have prioritized multimodal pain management and minimization of opioid use. Of course, as this audience knows very well, it is well established that an increase in opiate use is associated with serious adverse effects ranging from constipation, sedation, even to death. Some spine surgeons aim to spare opioids by routinely prescribing muscle relaxant drugs to patients after spine surgery. The question is, does that work? Does that actually spare opioids? We became interested in this research question when we noticed that some of our rehabilitation inpatients were taking muscle relaxers as they rehabilitated after spine surgery. A closer look showed that some surgeons at our medical center routinely prescribed these drugs to almost all of their patients, while some of the other surgeons rarely or never prescribed muscle relaxant drugs to their post-op patients. This suggested a potential research opportunity. When we looked into it, we found a 2016 double blinded randomized control trial out of Copenhagen, which looked at the effect of a muscle relaxant medication, fluorozoxazone, on pain after spine surgery. And this study was both cervical and lumbar spine surgery. They enrolled 110 patients with a VAS score greater than 50 in the immediate period after surgery, within the first couple hours. And half of the group were randomized to placebo. Half of the group got 500 milligrams of fluorozoxazone. These patients were also put on a morphine PCA pump during that period. Data was collected on pain and total opioid use for all the patients. The trial did not show a significant difference between groups in the primary outcome measure, which was VAS score during mobilization, two hours after inclusion in the study, and showed no significant differences in the secondary outcome analysis, including total opioid use, within that two to four hour time window. We thought the study was interesting and pretty well designed, but it shed no light on opiate use in the subacute period after surgery, or the period just after surgery when the patients come under our care. Our study sought to examine whether muscle relaxant use is associated with the total change in opioid use over the three month period following lumbar spine surgery. Our study was designed to take a retrospective look at subjects from a Sarin Academic Medical Center, who were identified via a query of our electronic health record. We received appropriate IRB approval prior to starting. Patients were categorized as either received muscle relaxers or did not receive muscle relaxers, based on a review of the query data. The muscle relaxers we included were cyclobenzaprine, tizanidine, methocarbamol, carisoprodol, and metaxalon. Cumulative oral morphine equivalent dose for the three month period after surgery was calculated for each group, and the data were compared using a two sample t-test. We can turn our attention now to table one on the poster. We see here that the muscle relaxer group of patients consumed an oral morphine equivalent of 1,779 milligrams. The interquartile range was about 500 to 2,100. In the no muscle relaxers group, the cumulative oral morphine equivalent dosage was 2,053 milligrams, with a interquartile range of 450 to 2,543. Though we see almost a 300 milligram difference between the group, favoring the muscle relaxer group, that result was not statistically significant. As we can see there, the p-value was 0.58. So we see in our study that the two groups did not demonstrate a significant difference in average cumulative oral morphine equivalent over the three month period following surgery. This study has several major limitations. We did not control for between group differences. It is plausible that the patients who did or did not receive muscle relaxers are fundamentally different groups in several ways. For example, we didn't collect data on which surgeon performed the surgery. We didn't collect documentation or attempt to quantify the extent of the surgery, the complexity of the case, the patient's baseline pain or muscle relaxer use, which of course may differ between groups. Moreover, our inclusion criteria for the types of spine surgery was intentionally very broad. Of course, several different kinds of studies could be considered going forward. Of course, a prospective study would be the best way to study this, but something that could also be done very cheaply and easily would be to do another retrospective study with more narrow inclusion criteria, which may better detect the impact of muscle relaxers on total opioid use after surgery, if indeed any effect does exist. So thank you for the opportunity. In particular, I'd like to thank my mentor, Dr. Kim, who assisted with this project. Thank you. Thank you, Dr. Hillary. That was very well done. Everybody at PGY-4 in Cleveland at Case Western, and he's going to do a pain fellowship next year. Our next speaker is Dr. Otterson, associate professor at the University of Washington. He's going to speak about electrodiagnosis of cervical dystonia in current clinical practice and associated conditions. Dr. Otterson. Well, thank you. I am Ib Otterson, as you know, and I'm delighted I have the opportunity to share with you how we diagnose and manage cervical dystonia in our rehab clinic here at University of Washington in Seattle. Yes, it has just stopped raining. We're okay now. The title was, as mentioned, electrodiagnosis of cervical dystonia in current clinical practice and associated conditions. Now, as you can see from the picture and you know, cervical dystonia is readily recognized and is the most common form of focal dystonia. Nonetheless, the diagnosis is often delayed for years, and I'm talking 3.5 to 6.8 years, which is a very long time, especially for the patients that they are not diagnosed correctly. But it may not be surprising because there are no specific diagnostic tests or laboratory studies required to make the diagnosis. Now, by the way, I just want to mention that the delayed diagnosis is well illustrated in the old anecdote you probably remember from medical school where a patient goes to the doctor with neck pain for years, but the doctor is not able to diagnose him until one day when the doctor sees a patient walking down the hall and he says, I know what he got. He got cervical dystonia. And sure enough, the condition had progressed to the point where it was readily obvious. Now, let us look at the diagnosis for cervical dystonia and the definition. And you have the right slide here. Stay with this one for a little bit. The definition is from the International Parkinson Movement Disorder and Society, and I'll read it to you. Dystonia is a movement disorder characterized by sustained or intermittent muscle contractions using abnormal, often repetitive movements, posture, or both. So you can see it's all a matter of posture and movement, and it's very subjective. So unfortunately, many patients will not meet the diagnostic criteria because there's some uncertainty here, and there's no really good definitions of normal and abnormal posture, and it's really up to the person and it's a subjective definition. So therefore, many patients will be undiagnosed and receive inappropriate treatment or at least undertreated as it is. So now the question is to all of you, is this cervical dystonia or not? I really would like to see a show of hands so I could know how many think it's one or the other. But let's look at the patient here. As you can see, she has a little bit of turning of her head to the right, but is this really because she's looking at the photographer or is it because she has dystonia? Well, you can tell. I mean, it's really difficult to determine when the postural abnormalities are mild. And so therefore, we have included an objective EMG exam in the assessment of cervical dystonia. We're using an EMG test to further help us out with the diagnosis. So now, slide number two. And this is with the patient after the EMG has been done, and you can see there's strong dystonia in many muscles on both sides of the neck, and clearly she has cervical dystonia. So that makes the diagnosis easy. Now, I prefer to have at least three separate muscles with moderate to severe dystonia in order to confirm the diagnosis. But it's all doable, and the patient has to be sitting in a very nice comfortable position, slumped a little, slouched a little bit in the chair so the head balances well on the shoulders, arms should be in the lap, and not strain the head or neck in any way so that we get an abnormal reading. So it's a little bit of a challenge to get a good reading and do it right, but it certainly is a helpful diagnosis when it's done. All right, so let's just look at the highlights from the study, and it was a retrospective study where we looked at 120 patients in the clinic. It's the next slide, please. Here we go. And they all were diagnosed with cervical dystonia. The two-thirds were females, and the average age was 49 years old of the whole group. So we then looked at the causes for cervical dystonia, and two-thirds had an event with trauma, and half of the trauma cases were associated with a motor vehicle crash. So we have a high percentage of whiplash injuries in this group. The second one was overuse, and the last one was other, which include neurogenic conditions such as cerebral palsy and stroke, et cetera. So a very high load of trauma cases. And then we looked at associated conditions above the neck and below the neck, and we found that in patients diagnosed with cervical dystonia, there was a very high correlation with cervicogenic headache and also thoracic out syndrome. So it's strongly significant for cervicogenic headache here. As you can see, the p-value is 0.001, and of course, 30% had thoracic outlet syndrome. Now, this may be because of referral source that we found so many trauma cases, but in this group, it's really interesting to see that there's a strong correlation with conditions above and below the neck. And it's probably because you have the cervical dystonia, tight muscles in the neck, and that will then compress the nerves such as the lesser and greater occipital nerves as well as the brachial plexus between the scalenes. And then you come up with these high correlations in trauma. Also, we found that hypermobility was common, and there was really no difference from the population in the whole study in terms of trauma or motor vehicle crashes. I mean, half of them were trauma and half was motor vehicle crash. So possibly, hypermobility predisposes patients to neck injuries. It sets off the dystonia, but it's something to be explored further. So far, it was borderline, in the borderline significant zone, and that's where we are. So I would like to finish up with my little clinical pearl here, and that is when an objective EMG exam is used for assessment of CD, then we found a significant correlation with cervicogenic headache and thoracic outlet syndrome. Now, if you look at this the other way around, then when these medical conditions are diagnosed alone, like headache and TOS, then it's most appropriate to further assess for cervical dystonia using an objective EMG exam. So hopefully, that will be useful for you in your clinical practice. Thank you very much. Thanks, Dr. Addison. That was really well done. Thanks very much again. Our next speaker is Dr. Hussain out of Albert Einstein at Alexandria University, and she's going to speak about incidence of diabetes mellitus type 2 and prediabetes among hand nerve entrapment neuropathy patients. It's an epidemiological study. Dr. Hussain. Do you have to unmute? Well, as a professor of Alexandria University in Egypt on unpaid leave, and I'm currently having my private practice, this study is done here in the United States, and it is called the incidence of diabetes mellitus type 2 and prediabetes among hand nerve entrapment neuropathy patients epidemiological study. The objective of this study, as well as the motive, was we all know that diabetes mellitus is one of the major causes and complications of the neuropathy. So neuropathy is among the famous complications of diabetes. So we'd like to measure the incidence of diabetes mellitus and prediabetes among patients with hand nerve entrapment syndrome, and this was a prospective cross-sectional study done on outpatient setting. 412 patients presented with unilateral bilateral hand numbness suspecting any hand entrapment syndrome, mainly carpal tunnel, were the inclusion criteria. Whether the exclusion criteria was any patient have history of cervical trauma or hand nerve injury or any other nerve injury, and the intervention was each patient was subjected to demographic data including his medical history, body mass index, occupation, and mainly the history of diabetes, and the clinical exam including full neurological examination, neck examination, including spurling study, spurling test, I'm sorry, and of course including in the neurological exam we include the Tyndall sign as well as a felon test for the carpal tunnel syndrome. Can you go next, please? The main outcome measures was doing nerve conduction and test for upper extremity nerves as well as EMG for the segment pointing muscles. The laboratory test that was carried out was a glycosylated hemoglobin or hemoglobin A1c as well as liver function and kidney function test. Cervical spine MRI was done as possible, not all the patients. The results of this study actually showed that the mean age was about 59 and all patients were right-handed and there was more female predominance, about 62. Body mass index was 32, the majority were manual workers and there was no incidence or almost negative significance with hemoglobin A1c below 5.5, but the significant incidence was arising on hemoglobin A1c, glycosylated hemoglobin and mainly was with prediabetes as well as frank diabetes, more than 7 hemoglobin A1c. There was significant incidence of the sensory carpal tunnel as well as sensory motor carpal tunnel and there was significant incidence of the Guillon-Canel syndrome and polyneuropathy. There was no significant incidence of the cervical radiculopathy, but there was significant incidence in cases with double-crotch syndrome and this was explained by the incidence of the carpal tunnel and as regards the pathology, the demyelinating showed no significant incidence of diabetes but the demyelinating axonal pathology showing significant incidence of diabetes mellitus syndrome. So we have concluded that there is a high incidence of diabetes mellitus and prediabetes among patients with hand nerve entrapment, mainly carpal tunnel syndrome and Guillon-Canel syndrome as well as polyneuropathy. Entrapment neuropathy may be the earliest neurophysiological abnormalities in diabetes mellitus and our proof for this is there is high incidence of diabetes mellitus and prediabetes with entrapment neuropathy. So actually the entrapment neuropathy could be the first sign to diagnose diabetes in case of prediabetes and the explanation for this due to the generalized metabolic abnormalities and consequently abnormal alteration of the glucose metabolism, which makes the nerve more vulnerable, especially in contained, constrained tunnels like the entrapped tunnels. That's why that couldn't explain why entrapment neuropathy, especially in hand entrapment can be the presenting sign for the diabetes and the status of the prediabetes test. And thank you so much. Thanks, Dr. Hussain. That was really, really well done. We're going to go on from that to Augustine Lee, who is currently a fellow at the Vanderbilt University doing his pain management fellowship, and he's going to speak to us about mindfulness as a mediator of pain reduction after Tai Chi exercise intervention among adults with fibromyalgia. Thank you so much. A small clarification, I'm actually a fellow with interventional spine, no problem. So sometimes in the world of clinical research and in the world of physiatric medicine, the question that we want to answer is how, not whether a treatment that we did work, but how did it work? So from an empirical standpoint, a mediation analysis, for those who don't know, is a series of regression models that can be used to identify whether a variable on the theoretical causal pathway for an intervention statistically mediated or accounted for the outcome that was found. So the how question that we wanted to answer in this study was how did one exercise intervention, in this case a Tai Chi exercise intervention, account for superior results in pain reduction as compared to an aerobic exercise intervention, which again, for those who probably already know in this audience, is the standard non-pharmacological, non-interventional treatment of choice in patients with fibromyalgia. So the parent study from which this study was derived was recently published that demonstrated that a Tai Chi mind-body exercise intervention was superior to an aerobic exercise intervention among these patients in a prospective randomized comparative effectiveness model. So what we did is, you know, we wanted to frankly identify whether or not mindfulness, which for people who may not know, mindfulness is essentially a quantified meditation. If you were to query experts from the field of integrative medicine and you were to ask them what's the secret ingredient of exercise modalities such as Tai Chi or yoga or Aikido, they would tell you that in addition to the physical activity that you would get from it, there's actually a meditative component as a part of that complex intervention. And so that in theory is something that distinguishes it from your standard exercise that you do at the gym or your standard aerobic exercise that you could do in an aerobics class. And so what we set out to identify was what we showed from the parent trial was that Tai Chi was superior to an aerobic exercise intervention in this patient population, but we didn't know how. And so what this study attempted to identify was whether or not mindfulness answered that how. Is this the secret ingredient that distinguished a Tai Chi exercise intervention from that aerobic exercise intervention? So the design was a secondary analysis of a single-bind randomized trial comparing these two interventions. The interventions that were received was either a 24-week, twice-weekly aerobic exercise class or various different kinds of Tai Chi classes that were split up either into just 12 weeks or 24 weeks, once or twice weekly. We were able to quantify mindfulness using a valid, reliable self-reported questionnaire called the Five-Facet Mindfulness Questionnaire, and then we quantified pain using an NRS pain severity survey tool. So for the mediation analysis itself, we used Baron-Kinney methods to evaluate whether or not the change in mindfulness mediated the reduction in pain that was found in patients who had the Tai Chi exercise intervention. So in our results, we ended up having 177 participants. In order to show that a successful mediation effect was found, one would have to demonstrate that the intervention itself not only independently affected the mediating variable, in this case mindfulness, but also that the intervention itself independently affected the outcome, which is pain reduction. And then the kicker is that the mediation variable would in and of itself need to independently affect the outcome itself. So in the schematic that you can see in the figure there, assignment to either Tai Chi or aerobic exercise would need to independently affect your improvement in mindfulness, meaning that those who were assigned to Tai Chi needed to have significant greater improvements in mindfulness compared to those assigned to aerobic exercise. Moreover, those assigned to Tai Chi needed to have greater improvement in pain severity compared with those who were assigned to aerobic exercise. And then the kicker is that independent of whether or not they were assigned to either intervention, the improvements that were found in mindfulness needed to independently be correlated or affect the reduction in pain severity among these patients. So what we found is that the participants who were assigned to Tai Chi did have significant improvement in mindfulness as compared to the patients who were assigned to aerobic exercise. And in addition, patients who were assigned to Tai Chi did significantly have greater pain reduction compared to those who were assigned to aerobic exercise. However, the change in mindfulness that were found from either intervention did not independently impact the reduction in pain severity that was found. And so what we can conclude is that mindfulness did not empirically mediate the reduction in pain that was found from this Tai Chi exercise intervention. And so even though the Tai Chi exercise intervention was superior to the aerobic exercise intervention, what we conclude from this experiment is that mindfulness may not be the substantial underlying ingredient, if you will, of this complex intervention that accounted for these results in this patient population. I'd like to give a special thanks to my mentor, Dr. Chen-Chen Wang, and Will Harvey, who mentored this study which was performed over at Tufts Medical Center in Boston. Well done, Dr. Lee. Well done. And my apologies for calling you a pain physician. My former colleague and partner, Curtis Lipman, would have smacked me by now for calling an international spine doctor a pain doctor, as we tried to make a distinction of that way back in the day. All right. Super job. Next up is Danielle Sarno. She's an assistant professor at the Harvard Medical School. And if I didn't forget, she goes to Spalding, as well as Brigham and Women's Hospital. Dr. Sarno. Thank you, Dr. Ellen. Good afternoon. I'm Danielle Sarno. And first, I'd like to thank all of the veterans for your service to our country. Next slide, please. Next slide, please. As you know, during the COVID-19 pandemic, telemedicine has become increasingly important. And early studies reveal high patient satisfaction with rehabilitation-related care. In our study, we aim to assess patient experiences with telemedicine visits in pain and spine care practices during the pandemic. As part of a quality improvement initiative, physiatrists specializing in spine and pain care administered an online survey after audiovisual telemedicine visits. This self-reported online survey covered various aspects of the patient experience, including visit type, duration of encounter, and the estimated amount of round-trip travel time saved. Participants were asked to rate their experience in relation to the telehealth visit using the measures excellent, very good, good, fair, and poor for the areas of communication with provider, addressing concerns and questions, developing a treatment plan, convenience, overall visit satisfaction, and value for a future telemedicine visit. We also included an optional opportunity to provide feedback on anything that was particularly helpful or any limitations to the telehealth experience. Next slide, please. Fifty-five patients completed the online survey after being seen for clinical evaluation and management of pain via telemedicine. Before we get into the ratings as shown on the slide, let's talk about who participated. Fifty-eight percent identified as women, 42% identified as men. The most common age range was 35 to 64 at 55%, and 36 of participants were 65 and older. Eighty-nine percent did not incorporate family, friend, or caregiver during the visit, and 100% had healthcare insurance. The most common telemedicine visit type were follow-up visits, and the most common duration of visit was 15 to 29 minutes. Now onto the ratings as noted on the slide. Eighty-five point five percent of participants rated their telemedicine visit as excellent for addressing concerns and questions, 90.9% for communication with provider, 83.6% for developing a treatment plan, and 90.9% for convenience. The estimated round-trip travel time saved through telehealth exceeded an hour for 56.4% of participants. Specifically, 27.3% of participants saved 90 to 120 minutes round-trip, and that includes parking, and 29.1% of participants saved 60 to 89 minutes. As you can see in figure one, overall visit satisfaction was rated as excellent by 90.9% of participants, or very good by 9.1%. Eighty percent of participants rated value for a future telemedicine visit as excellent, and 14.5% of participants rated value for a future telemedicine visit as very good. So what we learned from this is that most participants found great value in the telehealth experience. Here's an example. A woman in the age range of 35 to 64 seen for follow-up visit for a spine condition rated all of the domains as excellent and commented, for visits where a physical exam is not necessary, such as my recent visit, telehealth is an excellent option. I didn't have to take time off of work, travel into the city, pay for parking, and travel in rush-hour traffic back home. This was very convenient and met all of my medical needs. I strongly favor continuing telehealth visits beyond the pandemic. Another comment from a participant was, since I am improving and a physical exam is not needed, it works very well. I still need the guidance and encouragement to continue my therapies and hear about other modalities that can be helpful to me. Also, I know that if I need to be seen in person, I can schedule an in-person visit. That is reassuring. We noticed that multiple comments included similar themes, such as ease of telehealth related to less travel burden, not having to wait in an office setting, and appointments being on time and effective. Next slide, please. To conclude, most participants in our study reported high satisfaction and value of telemedicine encounters conducted for outpatient pain and spine care practices. Future studies in telemedicine may evaluate expansion of telehealth into current practice, including use of telemedicine specifically for post-procedure assessments and imaging review visits. Next steps include resuming survey administration in a larger cohort, analyzing data from different periods of the pandemic, and quantifying spine physiatrists' experiences. As I've noted through the comments and through my experience, telemedicine has been very useful for my patients who are following up for their debilitating pain, requiring less sitting in the car, and less overall stress to arrive for their visit. I've been getting a glimpse into home environments, and by spending 100% of the time during the visit together face-to-face, I've been developing even stronger connections with my patients. So I found telehealth to be a positive experience. I'm happy to answer any questions at the end of this session, or feel free to reach out to me at dsarno at bwh.harvard.edu. Thank you. Thank you, Dr. Sarno. Very well done. Our final presenter today is Dr. Schnitzer. He's a professor at the Northwestern University Feinberg School of Medicine. He's going to speak to us today about treatment satisfaction with medications prescribed for osteoarthritis. It's a cross-sectional surveys with patients and physicians here in the United States. Dr. Schnitzer. Thank you very much, Dr. Owen, and I'd like to thank the organizers for allowing us to present these data today. So my co-authors and my disclosures are at the bottom of the poster, which is in a very small type, but I'd like to note that this work was sponsored by Pfizer and Eli Lilly and Company. We know that satisfaction with medications prescribed for osteoarthritis varies and this satisfaction may impact adherence, clinical outcomes, and quality of life. Previous studies have looked at satisfaction associated with changes in symptoms, but other factors including clinical factors, types of treatment, and patient-reported outcomes have not been studied. So this study was aimed to evaluate factors that were associated with the overall satisfaction with medications from the perspective of both patients with osteoarthritis and their physicians. So we turn to the methods. The data were collected using basically a cross-sectional survey conducted by Delphi Company that was conducted in the United States between February and May of 2017. The participating physicians were primary care physicians, rheumatologists, and orthopedic surgeons who completed patient records forms on what was asked to be their next nine consecutive patients with osteoarthritis. Each of the patients was also invited to complete a questionnaire about their osteoarthritis and the currently prescribed medications were included in the analysis. Patient-reported and physician-rated overall treatment satisfaction with medications prescribed for OA was assessed on a five-point Likert scale from one which was very satisfied to five which were very dissatisfied. Physicians were asked which of the following options best described your overall satisfaction for the prescribed medications and physicians were asked which of the following statements best described your satisfaction with the patient's prescribed therapy. The factors assessed for association with treatment satisfaction included a range of patient sociodemographic characteristics, clinical characteristics, markers of osteoarthritis severity and treatment history, and covariance included in the multiple linear regression included race and gender plus all the significant covariance from the bivariate comparisons with outcome. And then the final set of factors was identified using LASSO which is another basically regression analysis. So what did we find? Well, responses were obtained from 153 physicians and 572 patients. Figure one which is in the upper right-hand corner shows that there were altogether 11 factors that were important for patients and six factors that are important for physicians that were unique and there were 14 factors that were important for both of them which is in the overlap of this Venn diagram. In a multivariate analysis, the factors that were statistically significantly associated with satisfaction are shown in figure two which is really that table below the Venn diagrams and figure two is statistically significant factors related to patients, figure three is for physicians, and as the arrow shows, the higher absolute values based on the beta regression numbers there were indicating a stronger effect. So what you can't see here but I will tell you is for patients, worse overall satisfaction was most strongly associated with lack of efficacy and rapid OA deterioration and greater satisfaction for patients was associated with presence of comorbid musculoskeletal pain. For physicians, the worst overall satisfaction was strongly associated with again lack of efficacy and treatment-resistant OA pain and greater satisfaction report that the best control had been achieved. Additional factors important only for patients included exercise whereas those only for physicians included adverse events and tolerability. So we therefore conclude from this survey of satisfaction that patients and physicians generally agree on many of the factors influencing the level of satisfaction with their medications. For both patients and physicians, satisfaction was most strongly associated with pain control which I think is not surprising and the additional important factors included physical activity for patients and adverse events from medication for physicians. And these findings we feel may be useful to assist with quality care initiatives that can be taken. Thank you very much and I also will be happy to answer any questions. Thanks Dr. Schnitzer. So it seems like every year the presentations get a little more sophisticated, the outcomes and the presentations that much better. Great round of people and now we can open it up to questions after we have a virtual round of applause for everybody. The field is now open to questions. And you can utilize your chat box if you'd like. And for Dr. Hussain, do you have plans for future research to look at outcomes from carpal tunnel release in patients with median mononeuropathy at the risk with diabetes versus without? Thanks. Yes, this is actually an ongoing study. What's happening is we would like to know actually whether the prognosis will be even worse with diabetes mellitus, which is expected or not. So this is an idea that's going to be the future, whether those diagnosed, those diabetic versus non-diabetic, what will be the prognosis of these cases? Okay. I have a question for Dr. Lee. Today is Veterans Day. The VA has gone into mindfulness management of chronic pain full bore. What are your suggestions to them? What are my suggestions to the entire VA? Well, I think it's important to identify the unique aspects of the study. This is a study that looked at a specific patient population. And so what we showed is that maybe mindfulness wasn't the secret ingredient for that intervention, but these are complex interventions. There's a lot of things that go into various exercise-based treatments, whether it be through exercise or whether it be through other modalities that we see in medicine. And so I think, you know, whether or not our findings are ready to apply to every single thing as it pertains to mindfulness, I think that would be frankly inappropriate. What I think that we did is that we were able to isolate a very specific sample, looking at two very specific interventions that in theory are different by this one mechanism. And so we were, you know, and so I think it would be a little presumptive, frankly, you know, to apply this universally, you know, to various different patient populations and various different interventions. That doesn't mean that mindfulness isn't great for you. That doesn't mean that. It just means that this wasn't the ingredient that explained the results of what we found. And so that's where I think it's important to exercise a little bit of restraint in terms of the application and interpretation. Okay, thank you. As we wait for more questions. So, Dr. Lee, you're sorry, Dr. Hillary, and your talk about utilizing muscle relaxants. How long would you think that you need to be on muscle relaxers for to get your best efficacy? That's a great question. The first study I cited just gave one dose perioperatively and that didn't seem to have an impact. It seems like maybe a few weeks is helpful anecdotally for patients, but I don't have any data to point to to suggest that. And that gets back to the point I raised closer to the start of the talk. It's entirely possible that a huge proportion of the effect generally with muscle relaxers and low back pain is that it aids patients and helps them sleep. That would be most important in the immediate postoperative period, maybe a week or two out. Yeah, so usually these type of medicines need time to load up and they have to go through different pathways in the body to be effective. So I would agree with that. So I see there's a question coming to Dr. Anderson, but there's nothing written just yet. But it looks like somebody's trying to get in touch with you about cervical dystonia. Maybe you can do some mind reading. I don't know. We can get Dr. Friedman to type out the rest of this question. Be great. So I guess my next question goes to Dr. Sarno and her talk about telemedicine. So it looks like it's a great thing to do for follow ups who are doing well and just need a little reassurance. But when patients aren't doing so well, it sounds like they're going to need to come in still and have a better fit or have another physical exam, not a better physical exam. I agree. I think when a physical exam is indicated and clinically, we can determine that the patient, I think, will do better with an in-person visit. I am finding with establishing connections with new patients as well, sometimes just having that full visit rather than getting checked in and the whole process that sometimes happens during a clinic visit, sometimes just the visit time starts and we're just there present together for me 40 minutes. Just getting to know the person, I feel like I've been able to establish a nice connection. So sometimes even for new patients when you're just and then we might say at their convenience to come in even next week for the in-person so we could have a focused physical exam, continue the conversation about our next steps. And that seems to work well for some patients. I think in a big city where you have to pay for parking and traffic's tough, it's probably a really good thing. That's what we noticed in the theme of those comments about parking and traffic. Yes, it's always parking in a big city. Dr. Lee, you have another question. Any other thoughts about mechanism of Tai Chi versus aerobic activity? That's a great question. You know, so there are other more sort of exercise physiology-based theories for why that intervention might be superior to an aerobic activity intervention. You know, patients with fibromyalgia, what the emerging research on pain sensitization demonstrating is that these are patients who have centralized pain. And so one of the thoughts is frankly that one of the big elements that might impact or might affect treatment response is the severity or impact of the exercise. So in other words, these are patients who probably benefit from lower impact versus exercise interventions rather than higher impact. And it's also in theory Tai Chi is something that's a little bit lower impact as compared to something like CrossFit or something like that. And so that might be an explanatory way for which the intervention was superior, but further research would be done on that. Certainly. Good answer. Dr. Addison, we have a couple of questions for you, and I'll pile them up back to back for you. Did you find that the anterior and medial scaling muscles were primarily involved in etiology of thoracic outlet syndrome, or were there any surprises? And it looked like there's a second one, but I lost it. Okay. It's a very good question. Which muscle is the most important? And I think it varies from patient to patient. It depends on the accident or the hypertrophy of certain muscles, et cetera. There's quite a variability. But we normally do assess the anterior and medial scalenes and the pec minor, even sometimes the subclavius if you have problems with the venous return and swelling in the arm. So all of them are important. I can tell you people who work a lot with their arms, they often have a large pec minor muscle, and I think that can be important. But we look at the size and the dystonia at the same time. So we do EMG-directed injections, ultrasound, and EMG-directed. So there's some variation. I mean, we can look at this, and we may end up doing that because we have all the recordings. So, but I really can't tell you. It's really variable. Thank you. So Dr. Sarno, is your practice using telemedicine for consults on new patients? And then there was a comment about insurance reimbursement is highly difficult in some places. Thank you. And so as I was mentioning, I do have a mix of new patients, so initial consultations and follow-up visits. And I see there's another question for me about what about the liability of performing telemedicine appointments following interventional spine procedures and potentially missing post-procedure infections? That's a great question. And I think using our clinical judgment, asking the right questions, getting to know a sense about fevers, asking about redness, erythema, any signs of infections, I think things can be missed with telemedicine, of course. But it also allows for a sooner follow-up, at least in my case. Sometimes it might take longer to get in for a follow-up in person, but I can see them within a few days virtually. Make time for them before or after clinic if you want to be flexible. So I think there can be less liability in that way of just being in close contact with your patients. But of course, not being able to physically examine, there are limitations then. And I'm happy to hear other people's perspective, too, if anyone wants to share their experience with concern about liability. It could be an interesting discussion. Let's see what else has come across. 177 people in the chat box, nobody else with another question. I see a question for me about insurance reimbursement. And we don't have any issues with it, fair and square reimbursement for cervical dystonia. I think if you have good documentation and tracings of the EMG assessment, then there's really no problem. There's really no problem. And that's all there is to it. Well, a super job today by our speakers. They've been called from over 700 submissions, gone through peer review, three rounds of peer review, and picked to be the best of the best. We thank you all. We give you another round of virtual applause and thank you for your time today. Thank you so much. Thank you. We'll see you next time.

pain and spine medicine

muscle relaxants

opioid use

Electrodiagnosis

cervical dystonia

hand nerve entrapment neuropathy

telemedicine

osteoarthritis