spotlight on the pandemic. I'm Monica Rowe. I'm going to be the moderator today. We have a great lineup of presentations from all the entire spectrum, as we were talking about earlier, from medical students to professors presenting today. So we'll just kick this off. We're going to have each presenter do seven minutes, and then we'll have time at the end for questions. So if you have questions in regards to an earlier presentation, please save it for the end. You can use the chat, and we will have time for questions at the end. So we are going to start with Dr. Katelyn Anderson, who is a doctor of physical therapy and a clinical assistant professor at the University of Wisconsin-Milwaukee. Thank you so much. Hello, everyone. My name is Katelyn, and I'm so excited to be invited to this and just to have an opportunity to talk to other members of the interdisciplinary team that I'm so used to working with. So I will be presenting my student physical therapist research groups project we did here at the University of Wisconsin-Milwaukee, where I serve as their faculty advisor. So a brief history on kind of where this project came about. I just moved to Milwaukee last year. Prior to that, I was working at NYU Langone Health in New York City when the pandemic hit, and I worked there in the ICUs for the next six months, only to move just in time to hit the Midwest peak of the pandemic, where I also work at a hospital here. So that's kind of where this project came about in seeing other health care professionals have to really brainstorm and meet a need without any guiding literature, and then also to note the changes in literature over the last 18 months certainly has been interesting. So I'll start by just saying we all know physical therapists have played a pivotal role throughout the pandemic. We've served on the front lines in the ICU. We have assisted with proning teams. We continue to mobilize patients for months and months on circulatory support devices like ECMO, and we've pushed for the utilization of telehealth. This review was conducted to help identify some obvious gaps in research related to COVID-19 complications, and specifically the cardiovascular or the CV system in order to establish some direction for best practice and hopeful future research. Knowledge translation for rehab professionals during this time has been a little scary and ultimately can differ region to region, so it's very imperative for those who are treating patients with COVID-19 across the continuum of care to understand the roles and decision making of each respective profession. Our research group ended up conducting three separate literature searches from October 2019 to June 2021 to capture the changing nature of the literature, and obviously there has been even more literature that has come out since June 2021, but this is what was included in this report. Inclusion criteria aimed specifically at CV complications and sequelae from COVID-19 infection. We also evaluated conventional and recommended CV interventions supported in the literature that are commonly performed by PTs from inpatient to outpatient, and those without a diagnosis of COVID-19. Several themes became apparent in our compiled search. The identification of common CV complications associated with COVID-19 infection, common comorbidities in patients hospitalized with COVID, and key pathophysiological aspects that sets COVID-19 infection apart from other viruses and disease. One major gap identified is how rehabilitation specifically implemented in those with moderate to severe disease with complication, as we often see in inpatient environments who go on to have long-term impairments such as post-intensive care unit syndrome. The method of an overall infection was frequently discussed in the articles. The hyperinflammatory cascade and resulting cytokine storm, however, was only discussed in about 18% of the articles, interestingly enough. This state of fluctuating and unpredictable hyperinflammation should directly play a role for physical therapist plan of care, decision making, and chart reviewing. I want to outline a few major complications discussed from the literature search as seen in figure two. The most common complication outlined in 36% of articles was actually venous arterial and microvascular thrombosis. Thrombosis may be exacerbated by immobility and increase the risk for vascular ischemia and stroke. 17% of the articles mentioned how COVID-19 can lead to myocarditis or pericarditis, often resulting in patient readmission to hospitals. Other complications included left ventricular dysfunction, reduced ejection fraction, and myocardial infarction or heart attack. Cardiac arrhythmias, including atrial and ventricular arrhythmias, were mentioned in about 9% of articles. Some arrhythmias were noted to lead to increased morbidity and mortality. Remaining notable complications included right ventricular strain, pericardial infusion, thrombosis leading to amputation, and general heart failure. Knowledge of these complications help guide the PT evaluation, chart review, and treatments of patients with COVID-19 and may be further exacerbated by the inflammatory nature of the disease. However, this was an identified gap in discussion, particularly in rehabilitation research. Four primary comorbidities associated with increased morbidity and mortality of patients with COVID were identified and included diabetes, mellitus, hypertension, heart disease, and obesity. Additional comorbidities were also mentioned and linked to an overall poor prognosis. Those included dyslipidemia, renal disease, COPD, and peripheral artery disease. From a PT perspective, many of these comorbidities can be addressed by direct education, medical management, and physical rehab and exercise, in addition to other lifestyle changes. This is an important consideration for PTs who promote health and wellness in the long term and prescribe specific dose exercise. From a known pathophys standpoint, the presence of increased inflammatory markers coupled with a suppressed immune response truly creates an ideal environment for severe oxygen supply and balance. It is well established that physical activity is beneficial for patients with CV complications not related to COVID. However, excuse me, in fact, physical activity after CV events can promote protection against future complications, decrease hospital length of stay, and improve overall mobility status to return to normal function. Early immobilization in the first 24 to 48 hours is now common practice across ICUs in the United States and around the world. However, these conventional treatment techniques and timeline for treatment may not be applicable in COVID-19 populations based on the known hyperinflammatory fluctuating state of the illness, particularly during the first 0 to 21 days of active infection with close monitoring during days 9 to 14. Extremely careful chart review of these inflammatory markers including C-reactive protein, ferritin, and troponin the day of active infection, oxygen trends, and immune response are vital not only to physical therapists but the entire medical team who is weighing how and when to mobilize these patients. Low intensity and carefully graded treatment may benefit patients throughout their early rehab journey to avoid exacerbation of illness. However, this may affect discharge planning and require communication with the medical team on timeliness of evaluation and treatment. This concept has also not been documented in discussion in rehabilitation research. Lastly, in those with a hospitalization for COVID-19, continued therapy services should be promoted in order to decrease long-term side effects. Formal exercise testing, spirometry, and specific outcome measure assessments such as the six-minute walk, the two-minute step test, 30-second chair rise may benefit PT assessment in subacute to outpatient settings to track some symptoms and improvement over time. Any patient with a diagnosis of COVID-19 who requires ICU monitoring and hospitalization should be screened for post-intensive care unit syndrome and provided PT referral as we know ICU stay is linked to devastating long-term outcomes. And that was it. Great. Thank you so much for presenting that to us. We're going to move on to our next presentation by Dr. Jennifer Goldman, who is a professor and section chief of Parkinson's and movement disorders at the Shirley Reinability Lab and Northwestern University Feinberg School of Medicine. Thanks. Thanks so much, Monica. And I'm delighted to be here today and share some of our work on telehealth with you all on behalf of my colleagues who also have been part of this project. And so as you all know, telehealth is not a new entity, but in March, 2020, it really blossomed and grew rapidly with the onset of the COVID-19 pandemic and public health emergency. And so in about two weeks time, our team at Shirley Reinability Lab got telehealth up and running for the rehabilitation hospital. And on March 30th, launched our HIPAA compliant telehealth program for rehabilitation therapies and physician practices. And these were held in both our outpatient and de-rehabilitation settings virtually in response to the pandemic. We conducted the physician visits synchronously. So with patient and provider in the same virtual setting, and in some cases included our interdisciplinary team clinic model with a physician, physical therapist, occupational therapist, and speech language pathologist seeing patients together. And in this model, this model was used by several patient clinics, including the Parkinson's and movement disorders group, pain management, and day rehab. So the objective of our study was to look at our patients' experiences and satisfaction with telehealth in the physician practice setting as described, and also in our novel virtual interdisciplinary evaluations. And so with this, a team of physicians, data scientists, physical therapists, and administrators designed a survey that was then distributed via email to patients who had received telehealth services from March, 2020 on implementing an electronic consent process as well. And so the data that I'll talk about today comes from surveys that were administered between December to March, December, 2020 to March, 2021. And the survey asked questions in multiple choice format or Likert scale format and free text to assess different domains. So telehealth logistics, how easy it was to get on and use the system. Did someone have prior use of telehealth? And what was their impression of the quality of services, comfort, safety from physical standpoints, privacy, and effectiveness in their overall satisfaction? And then we analyzed the responses. And here I'll present our first 101 survey responses that came from about 2,800 encounters by about 1,800 unique patients from the physician practices. And as you can see in the demographics of the respondents, about 68% of them were between the ages of 50 to 79. More than half were female. The majority were Caucasian. And of these, 95 respondents had completed a telehealth visit. Interestingly, about 15% was after their first visit and about 85% with follow-up visits. Most used a video conference platform, so about 89% using video conference. And about two-thirds had not received telehealth services at Shirley Ryan Ability Lab before. We had a wide variety of diagnoses for whom we provided care, including musculoskeletal disorders, neurologic conditions, chronic pain syndrome, traumatic brain injury, and pain. And overall, their responses, I'll just summarize them briefly here. In the majority rated, video conference use is fairly to very easy. We have high satisfaction ratings for its effectiveness, comfort, physical safety of moving about on the camera, privacy, and the ability of the provider to give the patient their full attention and recommendations. We found that people felt the benefits of telehealth included less cost for travel, less time for travel, didn't need to take off work or have transportation arranged, and those were perceived very highly. In general, the diagnoses each had a high satisfaction rate, a little bit of nuanced differences across the different diagnoses, but overwhelmingly with positive responses. Of the telehealth patients, 14 participated in the virtual interdisciplinary care clinic, and about over 75% strongly agreed that this format worked well. So each person was in their Webex box delivering care simultaneously, and they felt that this provided multiple perspectives at the same time, integrated care, and provided effective communication to address both physical and mental health symptoms, even in the virtual format. Overall, the strengths of our study lie in its multidisciplinary team approach, both in its design and its implementation, our ability to distribute the survey after each telehealth appointment through our electronic data warehouse and electronic consenting process, and to be able to look at this novel delivery of team care clinic in virtual formats. Our survey size is relatively small, although we're still collecting data from people who are still getting telehealth, and I think in the future we'd like to see broader representations across diverse populations and to understand why those who may not have or be able to access telehealth, how we could provide care for them. So in summary, telehealth in our rehabilitation settings, as provided by physicians and our team clinics, was overall well received and effective by the survey respondents. And these findings will help us deliver better care and inform best practices, as well as hopefully continuing the ability to deliver care via telehealth. And with that, I will thank you for your attention. Thanks, Dr. Goldman. I appreciate that summary of your study. We're going to move on to the next presentation by Dr. Claire Finkel, who is an assistant professor at the University of Missouri, and she's going to be talking to us again about telehealth, but early outpatient tele-rehabilitation improves functional outcomes in patients following hospitalization for COVID-19, a case series. Thank you, and thank you all for having me here today. So the title of my study is Early Outpatient Tele-Rehabilitation Improves Functional Outcomes Following Hospitalization for COVID-19. I'd like to start by thanking my co-authors, Dr. Jennifer Stone and Chelsea Harrison, our colleagues in the Department of Physical Therapy, Kelly Buchanan, who is a clinical research coordinator here at Mizzou PMR, and of course, Dr. Greg Warsiewicz, who is now at Mayo Clinic Jacksonville. Next slide, please. This study assessed the impact of early outpatient tele-rehabilitation on patients following hospitalization for COVID-19. To the best of our knowledge, research in this area was sparse at the time of study design, though there was knowledge of significant functional deficits that could potentially benefit from outpatient rehabilitation services. The study took place at a tertiary academic medical center in the Midwest, which serves as a cashment facility for surrounding rural areas. All COVID-19 discharges between April and September of 2020 were invited to participate, and so out of these 50 potential enrollees, we did have 18 individuals that enrolled and completed the full study protocol. We also had six patients that did enroll, and they did their initial therapy evaluation, however, then withdrew after that initial session, and then we had 26 patients that declined to participate in tele-rehabilitation. Statistical analysis was performed and showed no variance in patients who accepted or declined therapy in terms of their age, sex, length of hospital stay, number of comorbidities, or number of days that they were ventilated. Demographics of the study showed that two-thirds of the study participants were female and a third were male. The mean age was 56, and we did have a pretty large age range, all the way from 24 years of age to 85 years of age. All patients who were accepted were scheduled for an evaluation visit within 72 hours of discharge from the hospital. All tele-rehabilitation sessions were completed via Zoom. Participants were given instructions on how to set up Zoom on their home devices, as well as detailed instructions on how to attend a telehealth visit using the platform, and a test visit was scheduled and completed prior to the first session to ensure that there were no technical issues or any tech issues were solved prior to the evaluation session. All physical therapists providing care to the patients went through the same training process, which included training on delivery of teletherapy services, proposed best practices based on data that was available at the time, and training on the protocol used in this study. The protocol was developed by a multidisciplinary team, and that included physical, occupational, speech, and respiratory therapists, as well as PM&R physicians. Patients were seen for two to four visits of tele-rehabilitation and were placed into predetermined activity tolerance categories with the corresponding rehabilitation plan. The decision to provide two versus three versus four visits of physical therapy was a collaborative decision based between the therapist and their patient, based on the patient's presentation and the therapist's best clinical judgment. The data gathered during the final session was utilized as the patient's discharge status, regardless of whether that was session two, three, or four. Next slide, please. Subjective and objective measures were taken at each visit and recorded for initial and final visits for analysis. Subjective measures included medication compliance, pain rating, Borg scale of perceived exertion while performing ADLs, self-reported severity levels, the daily fatigue impact scale, self-reported dyspnea, and presence of any sleep disturbances. Objective measures included respiratory rate and a 30-second sit-to-stand test. Subjects were also evaluated for occupational therapy, speech therapy, and mental health needs, and were referred out accordingly. Demographic and historical data collected included age, gender, comorbidities, and cognitive and physical status prior to diagnosis of COVID-19. These tests were chosen based on whether they could be accurately performed using the telehealth platform, so without touching somebody, and were based on measures that had been used and shown to be reliable in individuals with post-ICU syndrome, COPD, or pneumonia, as again, there was very little research available on rehabilitation of the COVID patient at the time of design of our study. Participants in our rehabilitation protocol demonstrated a significant improvement in multiple functional outcome measures when seen over a one- to three-week period following hospitalization. A series of paired t-tests revealed significant improvement between pre- and post-scores in respiratory rate, the 30-second sit-to-stand test, as well as daily fatigue scores. A series of Wilcoxon-signed ranked tests showed significant improvement between pre- and post-scores in BORG and self-reported severity level. An unexpected finding at the time of our study was the frequently identified need for occupational and speech therapy services in patients that were diagnosed with COVID-19, though I would like to acknowledge that this is now a well-known need in post-COVID patients. In our study, this need was not restricted to patients who had been in the hospital for extended periods or those who had required mechanical ventilation. This finding points to the likelihood that patients with COVID who are not severely ill may still experience significant cognitive and or language deficits and should be screened for need for these services. Because the high utilization of these services was not anticipated prior to implementation, a protocol for occupational therapy and speech therapy screening was not created. Future researchers should consider implementing such a protocol and gathering more specific data on cognitive impairments and outcomes. Next slide, please. In conclusion, in this study, we found that telerehabilitation is a feasible option to provide safe and effective services after hospitalization for COVID-19. In addition to being a useful therapy method while patients are still under quarantine or isolated, this method of delivery is relevant for hospitals that serve a large geographic area and have patients that have barriers to obtaining therapy closer to home. In closing, thank you for your time and attention, and I'm happy to take questions at the end of the session. Okay, thank you, Dr. Finkel. I appreciate your perspective. All three of these first cases have a lot of overlapping themes to them, so of course that makes a lot of sense that they were all grouped together. We're going to move on to a few case reports that we have now. I'm going to introduce Dr. Paul Andrews. He's a resident physician at the Carolinas Medical Center in North Carolina. Dr. Andrews, take it away. Thanks so much, Dr. Rowe. Like she said, my name is Paul Nielsen Andrews. I'm a third-year resident at Carolinas Medical Center in Charlotte, North Carolina. I have no disclosures to make about this case report. I did this with Dr. Edward Ferencz and in collaboration with Dr. Bobby Alexander of Ortho Carolina. Our research is a case report of an interesting patient with AIN syndrome, or anterior interosseous nerve syndrome, following a COVID-19 infection. We are hoping to highlight the importance of accurate and timely screening in this patient population, given that COVID-19 is not only cardiovascular and respiratory disease, but also neurological sequelae exist too. just some background about the anterior interosseous nerve or AIN, it's a pure motor branch of the median nerve. Um, it arises from the medial and lateral cords with contributions from the superior, middle and inferior trunks. It innervates three muscles of the forearm. Um, the flexor pollicis longus, the flexor digitorum profundus, um, the lateral half and the pronator quadratus. It controls flexion of the thumb at the IP joint as well as flexion of digits two and three at the DIP joint. It's kind of hard to isolate there. And it also contributes a little bit to the pronation of at the wrist. As such, uh, AIN syndrome is a palsy of these muscles. Um, it comprises about 1% of upper extremity palsies. So not a lot. It's pretty rare. Um, it's classically seen as a painless loss of function and function being flexion strength at the thumb, at the IP joint, uh, the index finger or middle finger at the DIP joint, and some loss of pronation strength. It's usually seen after penetrating trauma, fracture, hematoma, and it's due to local compression in that area. But it's also seen after viral illness as a result of neurologic amyotrophy, also known as Parsonage-Turner syndrome. Um, on physical exam, you'll be able to see the patient can't make an okay sign and they'll have no sensation deficits. Uh, NCS and EMG findings will show normal nerve conduction studies and abnormal EMG at the, uh, FDP, FPL, and PQ. Um, this brings us to our patient. She's a pleasant 59 year old right-hand dominant female with a recent mild COVID-19 infection. And importantly, she was not hospitalized for this. Um, and she presented two days, uh, paresthesia and weakness in her right upper extremity. Um, she woke up like this. She denied any trauma, no injury, no surgery. And like I said, no hospitalization for that COVID-19 infection a few weeks before. Um, she did have some subjective paresthesias in her biceps and forearm, but no pain. Uh, her main complaint was weakness and inability to fully flex her right thumb at the IP joint and gripping activities were challenging. Um, on her physical exam, she had five out of five strength in all muscles, except for one out of five strengths in her right thumb, IP joint and her distal interphalangeal joints, um, index finger, and a little weakness four to five strengths in wrist pronation. Um, on my poster, you can see that she was unable to perform the okay sign on nerve conduction studies. Her results for, um, sensory and motor were normal across the board. And then if you look down to the EMG results, you do see some abnormalities. You see increased insertional activity. You see positive, um, fibrillation potentials, positive sharp waves, polyphasic action potentials, and reduced recruitment in the flexor digitorum profundus and the flexor collicis longus. Uh, the pronator quadratus or PQ was deferred for patient comfort. And we already had two AIN innervated muscles tested. Um, AIN syndrome has been described as a result of neurologic amyotrophy or Parsonage Turner syndrome. It's commonly precipitated by an immunological stressor, uh, viral illness included. Um, so in the absence of any right arm trauma, this patient's presentation was most consistent with, uh, neurologic, um, uh, amyotrophy after COVID-19 infection. Um, this adds to the growing body of evidence associating these two, uh, disorders. Uh, COVID-19, um, has been shown to, uh, result in neurologic amyotrophy. And in the literature, you can find MRI evidence, but to our knowledge, this is the first EMG evidence of AIN syndrome following COVID-19 infection. So to wrap up, uh, COVID-19 has been implicated in a variety of direct and indirect neurological sequelae. There's a growing body of evidence, um, between these two. And so this ultimately just highlights the importance of accurate and timely neurological screening in this patient population. Um, so I'd like to thank Dr. William Bachnik, Dr. Vu Nguyen, Dr. Bobby Alexander, Dr. Edward Ferencz, Dr. Mark Hirsch and Dr. Mark Newman for all their input in putting this, um, case report together. Um, I appreciate your time and attention. Thanks all. Thanks, Dr. Andrews. Um, very, very interesting cases that are coming out. I think of all the different complications that COVID can be involved with. So thanks for sharing, uh, your experience with that, um, that particular case. So our final case of, uh, this morning's session is, um, going to be dual presented. We actually have, um, Dr. Charles, uh, Wong, who is a PGY3 resident. And we also have Dr. Kevin Wong, who is a fourth year medical student, um, both, uh, at, uh, Sunrise Health Graduate Medical Education PM&R program. So they will be presenting to us jointly a case. Thank you. Um, so hi, my name is Kevin. I'm an OMS 4 at Troy University, Nevada. Um, we, uh, Hi, I'm Charles Wong. I'm a PGY3, uh, at, uh, Mountain View Hospital in Las Vegas, Nevada. And we're presenting our case report of a severe CVA in a young post COVID patient. So, um, the patient is a 31 year old G2P2 non-smoking female with no past medical history, no medications, no history of alcoholism or substance abuse presenting with the right MCA, uh, distribution subacute infarct. Um, when she, uh, she presented a code, what was called, and we got the head CT shown on the poster here. Um, it showed a hyperdense MCA acute extreme stroke and, uh, on a CT angiography and CT angiogram, it showed a partial occlusion of the distal M1 and M3 segments with distal emboli. The further workup through her hospital course revealed no significant cause for a CVA. Um, her hypercoagulant profile and autoimmune profile was negative. And just further exam was negative for any other glaring causes for stroke. The only thing that we did find was that she had a, um, history of birth control use. So she had the Mirena IUD used for five years, three months prior to CVA. And then two months before she had an Xplanon inserted. Um, so we had OB and a gynecology consult, and they rolled out that progesterone only, um, birth control was a cause for the stroke and further research of a metal analysis of 26 articles showed that through the systemic review, um, there was no increase of any venous or arterial events secondary to progesterone only contraception. So at this point, neurology has ruled this stroke to be a cryptogenic stroke. Um, and then, um, with, uh, with further discussion with the patient, well, she said that she had a self limited month long COVID infection three months prior with no need for hospitalization. And, um, neurology had deemed this as a cryptogenic stroke with high suspicion for COVID coagulopathy. So once the patient was stabilized, she was transferred to the inpatient rehab unit, sorry, rehabilitation unit, where she improved moderate, moderately across the scores for her care scores, especially in her eating and also in her toileting, um, through a 16 day rigorous therapy through physical therapy, speech, and, uh, occupational therapy. She was able to safely discharge home without patient PT, OT, and ST services after completing family training. As far as DME is concerned, she was given a manual wheelchair, short base, quad caning, shower chair. Um, we wanted to follow up with a patient, but unfortunately we were not able to reach out to her after she was discharged. So this case occurred in early 2021 when information about post COVID syndromes and pathologies was pretty sparse. Now today we know that COVID-19 actually attacks endothelial cells directly through damaging the ACE2 receptor. Um, and this occurs throughout the entire body. However, even more recent research, um, shows, this was actually published last month, um, shows that COVID-19 actually has specific mechanisms affecting brain endothelial cells specifically, which we don't fully understand yet at this point. So this case is particularly important because it demonstrates just how severe, uh, post COVID-19 coagulopathy can be and its implications for rehabilitation. Uh, our patient was this young, uh, athletic patient. Her BMI was 19. Uh, she had absolutely no, uh, risk factors for CVA yet she had such a devastating case. Um, on top of that, her COVID-19 infection was a mild self-limited, uh, case. You just stayed at home for four weeks, uh, and then just self-resolved. So, uh, post COVID-19 syndromes are now known to be some of the most fearsome consequences of COVID-19. Uh, a trial done in early 2021 in Switzerland looked at 431 patients, uh, who were hospitalized for COVID-19 and 10% of them were re-hospitalized in the following six to eight months for complications of COVID-19. Um, currently though, the American Society of Hematology Guidelines, uh, actually recommend for, uh, no anticoagulation for mild COVID-19 cases such as our, our patient here. Um, of course our case kind of seems to suggest that maybe these guidelines need more work, need to be updated. Um, the American Society of Hematology Guidelines only recommend for hospitalized patients to, uh, receive anticoagulation long-term after discharge. So some, some of the current trials that are ongoing, uh, looking at the efficacy of anticoagulation include the ACTION trial. Um, I think this is the most recent one. It was published in June, 2021. Uh, it looked at anticoagulation of hospitalized COVID-19 patients of, and the anticoagulation ongoing for up to 30 days after discharge. Uh, and they looked at Lovenox, uh, Rivaroxaban, and they had about the same efficacy, but unfortunately they couldn't make any conclusion about, um, so-called long COVID, uh, complications such as our patient because they only looked at it for 30 days afterwards. Additionally, they only looked at patients who were hospitalized for COVID-19, unlike ours. More recently, a new trial called the Michelle trial, uh, has not been published yet, but it was presented, I believe, uh, sometime last week. Um, and it looks at a similar population to the ACTION trial, again, hospitalized patients. Um, and they looked at a period of 35 days of anticoagulation after discharge, but they do recommend, it looks like the initial data is recommending strongly for, uh, anticoagulation after discharge. Nevertheless, um, as these new data come out, um, we believe that longer term anticoagulation should be studied. Um, that's kind of what our case here is illustrating, uh, because our patient had her stroke, uh, many months after her mild case of COVID-19. Um, again, a lot of these trials are continuing to be ongoing, and I think they'll help inform our decisions, uh, as rehab physicians as well, as we are the ones often taking care of these consequences of COVID. Um, thank you for your time. Well, thank you, Dr. Wong. Thank you for, uh, and thank you, uh, med student Wong for that, uh, great case presentation. I really did, uh, I appreciated the fact that you, um, had ruled out that the OCP, that, or actually not an OCP, but that the IUD was not a factor, because obviously, because obviously in that age range, that's what we see, um, most commonly. So, so I thought that was nice that you did your due diligence on that. Um, all right, well, um, all of our presenters really took, uh, the time limit to heart. So we actually have ended a few minutes early, which is great because now we have, uh, an abundance of time to go over questions from the audience. So we will take questions through the chat. Um, we'll also take questions if you are brave enough to come off of mute, we would love to hear your verbal question as well. So, um, I am going to open it up to the audience for questions, uh, right now. So please go ahead and put things in the chat, um, and I'll read off the questions, but in the meantime, I, I'll kick it off with a couple of questions that I had myself. So, um, Dr. Anderson, um, you know, I, I thought that your, um, presentation highlights some really nice gaps, um, that are out there, but of course this growing body of literature is probably just continuing to be this huge monster. Um, could you talk a little bit about, you know, your thoughts on the role of cardiac rehabilitation and all this, since what did you see out there in terms of formal cardiac rehabilitation and programs out there that are available to people? Um, and I was predominantly, I am predominantly ICU therapist. So really we promoted inpatient rehab to outpatient cardiac based rehabilitation for anyone really that had, that was medically stable and also outside of that, like hyperinflammatory state. So sometimes, unfortunately the patient would need to be discharged home with home services and then almost do kind of like a backwards next level of care that what we're used to, they might need to go home for a little bit and then go to rehab or go to a sub acute and then to an inpatient rehab, unfortunately, because their signs and symptoms were very prolonged and they needed a little bit longer medical management before then they could like really, um, participate in cardiac rehab. The other limiting factor is that the oxygen need was very, it's a huge, I'm sure everyone here in this session knows this, the huge oxygen barrier and profound desaturations that have pretty much like blown all oxygen parameters with exercise out of the water. So I think that's a constant struggle for cardiac rehab. When we, um, when we recommend patients going to cardiac rehab, they get there and they say, you know, this person can't participate because their oxygen is dropping below 80 and they're still maxed out on O2. Unfortunately, that's the case for a lot of these very severe cases because they're showing some fibrosis of the lungs. Um, particularly those that had to be on ECMO. Yeah. So we are recommending that they go. I think the take home point is that as a lot of other people alluded to, um, these patients are going to have to have some form of rehabilitation probably for the next year. And it's like our job to figure out how we can get, get it to them. But, um, I think the recovery and the, some will not return to function, but that return to function is just going to take a lot, lot longer. Yeah. Yep. Thanks. Um, again, uh, if, if I'm missing your question, please just shoot me a direct chat, but, um, but I don't see any questions yet in the chat. So I'm going to move on and ask Dr. Goldman a question in full disclosure. I am on the author line of Dr. Goldman's presentation. I feel like I have to fully disclose that I contributed to the formation of the survey. However, Dr. Goldman did the bulk of, um, the data analysis and the work on this presentation, but, um, you know, Dr. Goldman, you said something really interesting about, um, the experience of an interdisciplinary clinic virtually. And I think that, uh, you have a very unique clinic and, um, I'd love to hear your experience because obviously your study was more about the patient experience. I'd love to hear your experience as a clinician, what it was like to conduct these, um, interdisciplinary evaluations in a virtual setting versus when everyone's together in the clinic. Sure. Thanks so much, Monica. And I think we were very keen on trying to continue our work of previously, you know, at the time of pandemic in-person interdisciplinary care where, you know, physicians, PTOG speech, our nursing staff were all in the same space. And then all of a sudden we couldn't do that at all from safety perspectives and COVID. And, uh, so we pivoted pretty quickly to try to have the whole team on video with the patient and their family. And I think a few takeaways from that experience, uh, personally, anecdotally, and from the survey, uh, are that one it's, it's certainly doable. Uh, I think we also found that we were able to appreciate new aspects of the patient and their family such that we could actually see their home environment. So we could see where they were walking, what sorts of, you know, couches they might be getting up from or placement of the, of the bed or obstacles, um, which was very helpful for the whole team. We were able to have children or family members from other parts of the country, even join in on that video visit, uh, because it was all virtual. Uh, and I do think, you know, much of our exam, we are fortunately able to do via telehealth or elements, um, that we can't test for rigidity or manual motor testing or, uh, different elements of balance, but we've learned how to do some workarounds and surrogates for those proxy measures. Um, so I think there's a lot of lessons learned, uh, ways to continue to, to improve it and optimize it. Sure. Right. Of course. Great. Um, well, a question from Dr. Anderson for Dr. Finkel. So, uh, she was wondering, uh, of those who elected not to participate in the telehealth study, but who are hospitalized, were they already receiving some form of home services and how many were on homo too? Did you track that information, Dr. Finkel? Yeah. Thanks for the question, Dr. Anderson. Um, I had my spreadsheet here, so I pulled it up. We did have five of the 26, um, that needed home oxygen when they left the hospital. Um, we did not track what other services they got, but anecdotally I could tell you that, um, we were kind of blessed here in Missouri. So we had those 50 patients over from March to September, which I know is so different from any other regions early in the pandemic. Um, so I would anecdotally say that those patients that left earlier on, we had more trouble getting services for, because so many things did shut down and we had so much trouble, um, getting people into the homes of post COVID patients. And of course, as the pandemic has gone on, there's more reassurance of the safety of following the protocol. And once patients are out of isolation and over their quarantine period, um, more of those patients are getting home services. So unfortunately I don't have the firm data on that, but you probably experienced similar things in your own setting. I would guess. Yeah. I was just wondering, cause I felt like, like you said, the lack of resources. And I just wonder how that has now affected all these people with long COVID, you know, who were unable to get services, but we're at home. So you have touched on, uh, some research, uh, that I would love to spring off of this on contacting these patients that opted out of our research, but, um, seeing if they would be willing to do a survey on long COVID type symptoms. I'm curious if early intervention with even telehealth, uh, rehabilitation, um, may have impacted risk factor for developing long COVID. As kind of a follow-up question, Dr. Finkel, you said there were 12% of people that withdrew, they enrolled and then they withdrew. What was their reason for withdrawing? Was it difficulty with time or they didn't feel like it was helpful? You know, did you, did you dive into why people started, but then stopped? Um, yes we did. Uh, so we unfortunately had a few no-shows, um, actually I'm looking at the data now. Most of them were just no-shows where they did the evaluation and then we just had trouble contacting them after that. And then one did the PT eval only and actually functionally, uh, did really well, but had more intense OT and speech therapy needs. And so, um, in that one, that data unfortunately got thrown out because it was the right thing for the patient to pivot more towards the OT speech therapy services. Yeah. Great. And then we'll do one more question here. Uh, Dr. Andrews, this is coming from, uh, Dr. Anderson, but I also had a very similar question, um, with your patient that you presented. Did you feel like there was any chance that there was some compressive neuropathy? So Dr. Anderson mentioned, you know, was she maybe self-proning at home and then doing something where she maybe compressed the nerve on her own? Yeah, she didn't repeat or she didn't report any, um, prolonged, uh, prone, uh, periods or pro or just prolonged supine periods for any reason. Uh, as well as I think the big thing here is that she was a healthy, uh, 59 year old lady. Um, and she got over her COVID infection, you know, fairly without any, um, major, uh, other issues other than this, this weakness. Um, but yeah, so no, she didn't report any type of, um, prone self-proning or, or self supining. Good, good, good. And then since we haven't been kicked off by our zoom masters here, we are, I'm going to throw one more question to Dr. Wong and then Kevin Wong. Um, again, similar to what Dr. Anderson wrote in the chat, um, were people, uh, was your case, was your patient able to return to normal function? Um, uh, to the function she was doing pre, um, pre CVA or what was the ultimate outcome for your patient? So, oh, it looks like, uh, I've been unmuted. All right. So, um, as far as her infection or the COVID virus, she had the one, um, infection and where she was just at home and essentially was not really symptomatic whatsoever. And prior to the CVA, she's completely independent with all ADLs, just had no, we, we asked her if she had any, any deficits afterwards and it was just normal function. Great. All right. Well, thank you all. I, I appreciate the discussion afterwards and thank you all for taking the time to, uh, come and listen to these wonderful presentations. I hope you all enjoy the rest of your day. Thanks to all the presenters. Nice job. Thank you. Thank you. Thanks, everyone. Thank you. Bye.

presenters

COVID-19 patients

telehealth

functional outcomes

therapy services

severe stroke

coagulopathy

interdisciplinary approaches