Good morning, everybody. Thank you for coming. I'm Alexios Karanopoulos. I'm the chair of the Evidence Committee, so I just want to thank all of you for coming and all of you who have contributed to our academy. We had over 1,100 abstracts submitted this year, some really excellent science. We're really pushing the science side of things in the academy, so I think the level of engagement has also increased and the level of importance to our academy has grown. So the purpose of this is just to really allow certain people that we've selected as the best of the best to really present and have an informal discussion about the abstract and learn in a very sort of constructive way. So that said, I'd like to welcome Dr. Eskenazi to the stage. Thank you very much. There is your thingy. Yes. I much appreciate the opportunity, and it's lovely to hear that the academy is trying to engage us in more scientific stuff. I really appreciate that. It's a shame that there are so few people, so we might need to work on figuring out a way to communicate out to other members about the importance of this so that we really take advantage of it. First of all, I want to acknowledge my co- ... I'm going to move around so that I can read correctly. My co-presenters. So I'm going to be talking about effectiveness of able botulinum toxin in adults with lower limb spasticity, and this is parts of the results from our really very large data from the Abolish Real World Observational Study. This is a study that has been ongoing for a long time and collected a very significant population of enrolling more than 400 patients, 430 in its initial version. And I want to acknowledge Rick Sorowicz, who's not here, Steve Ashford, Matthew Venetou, Pascal Maisonov, and Christian Haynes, and Jorge Cinto, who have been my collaborators in doing this work. And since I can't see the slides from this side, I'm going to continue to stand on this side. I hope you don't mind. So this is a very large study that really is not as complex as it appears in this slide. As I'm showing you, this is really the poster that we created for this presentation. I'm going to move to the next slide to try to... Do you want to use this? Oh, that's fine. Don't go too far. I found one. It's fine. Wait. I found a... Oh, there it is. I have another one. Okay. I have three microphones. Sorry for the interruption. You might see clearly that this is an important presentation now. So it's not advancing. You have to point it here. Point it down. The keyboard's over here. You have to point it... Oh, point it over there. Thank you. I'm pointing the wrong direction. Just push the button. It'll be the easiest if you can do that. It's not getting there. It's not moving. So there you go. Thank you very much. So the background and the objectives are laid out here. Really, I think it's clear that the efficacy of all of the botulinum toxins, but particularly abobotulinum toxin, which is the one that we use, also known as Dysport, in reducing adult lower limb spasticity has been established in multiple clinical trials. And I was fortunate enough to be part of the control clinical trial. They got approval for this in the U.S. and in other countries. But really, the idea of using goal attainment from real-life trials is not there. There is not a lot of data. And so that was the intent behind this ABOLISH study, which was a prospective longitudinal study that took 16 months in tracking individuals. And it was in nine countries, and we had 46 centers across those nine countries. So a large database. And what we did is we assessed longitudinally the goal attainment after the first or more abobotulinum toxin injection to the lower limb over the 16 months that we tracked the patients. And we then measured goal attainment scaling the LEG-T score in a routine clinical setting. And the inclusion criteria where patients needed to be adults over age 18, they needed to be able to walk a few steps, and we used five steps as the minimum number. They could do that with or without assistance. They needed to have a diagnosis that was documented of lower limb spasticity that was unilateral. We wanted to be sure that they were not bilateral. And that there was a decision to inject abobotulinum toxin prior to the enrollment. And then, of course, because this was a study, we had informed consent that was approved by the patients. Oops, sorry. You moved, I moved. There we go. Thank you. We enrolled 430 patients into the study. Of those, we treated 416 of them. As you could see, we were able to measure effectiveness in 384 of those patients. And, of course, they were in six cycles of injections over the 16 months. And you can see that by cycle six, we had very few patients. That's not that the patients did not get injected again. It's just that by the time they got to the sixth cycle, we were running out of time in the study, and we needed to end the study. And there were patients who moved to other places, and so we ended up losing them as a result of that. But if you look at the study from the first cycle to the fifth cycle, that was a lot of patients. Over 200 patients through the whole process. And we had 103 patients who withdrew from the study. You can see that 15 reported lack of efficacy. 14 did not meet criteria. We had one center that recruited patients that were not the kind of patients, unilateral, related to the study. And then we lost, to follow up, 14 patients, and 11 patients decided to withdraw their consent. We had very few adverse effects, nine patients. And then other reasons, 40 patients. So that's how we went from the 416 to the 327. If you look to the right side, of the 384 patients that were placed into the effectiveness set, the group that got at least one injection or more, you can see that the mean age was 54 years. We had more male than female, and that's not unusual. I've looked at this across the world. The tendency is that women take care of men, and so they get care, and that's not always true the other way around. As unfortunate and as demeaning as it sounds, it is something that is not happening. An opportunity for really, create more equity in care delivery. The diagnosis of conditions leading to spasticity were essentially three major groups. We had acquired brain injury, and we include stroke and traumatic brain injury and other brain injuries. We had spinal cord injury. So you see here there are eight patients that really we should not have included in the trial, and then there are others. And when you look at the etiology, the great majority had vascular problems, stroke-related, infarcts or hemorrhage, trauma to the brain, and then others. And the great majority of patients had lower limb involvement, but you could see their upper limb was also involved. Immediate time since onset of the event was 4.6 years, 4.7 years, a long wait. Another area of really poor care. We need to improve in the timing of care. And 76% of the patients had had a prior treatment with botulinum toxin. And the medial interval between the onset of event and the first injection was 1.3 years. I'm hurrying up, I know. No, no, take your time. Here I'm just showing you the change in the cumulative gas leg T-score. You probably are looking at me and saying, what the hell is that? The gas leg T-score is essentially a functional measure, and it has three major groupings. It has a passive function, you know, can you put your socks, can you put your pants? It has an active, can you transfer from sit to stand, can you remain standing? And then has an active functional, meaning can you walk around, can you get around? And when we use this, what you could see is that the cumulative gain of the change or the improvement was nearly 10 points. We went from 38.0 to 48.2. Meaning that this patient's had a significant, minimally clinically important change in their score. And it is something that has not been measured in the past in the real world. And so this was very important. And you could see the change in the treatment cycles over time, and at the very end. So let me talk just briefly about the safety and then I'll go into the conclusions. There were 94 adverse effects reported in this study by 56 of the patients. So we had a 13.5% of reports. 10 were considered to be treatment related. That's 1.4%. And four of them had the potential of leading to death or three participants were reported. But really none of these were reported related to the study treatment. So it was adverse effects that were not related. In conclusion, let me just tell you that this is the largest international observational study that provides evidence of benefit of repeated cycles of botulinum toxin. In this case, Able botulinum toxin to the lower limb for patients who have spasticity. Treatment with Ablebunt is generally well tolerated. There were no new safety issues identified. And when we looked at this through a multivariate analysis, we demonstrated the importance of appropriate injection guidance technique. So those patients, remember this was a real-world study, so we didn't force patients or clinicians to one way or another. But those clinicians that use localization, EMG, electrical stimulation, ultrasound, or a combination of those, had better outcomes than those that didn't. And that's really the major contributor of this. Encouragement to those that inject botulinum toxin for spasticity to use localization. It is important. So with that, I thank you for your attention. And if there are questions, I'll do my best to answer. Thank you. more multi-center international trials. And I know, having been there, I know how much work that is, so kudos to you. With regard to some of the safety issues and localization, do you think there was a direct contribution of that to the complications that were seen? And given that this is a multinational trial, is there a training effect that may portend the results? And does that also come into play with the time to onset of treatment, the 4.7 years? Yeah, thank you for those questions. I don't think that the effects or the adverse effects were in any way related to the use or not use of localization. I don't think that we can get to that level of detail. But definitely, we see now from this a clear opportunity that we need to train individuals on appropriate muscle localization for injection. So I always say that there are five factors that really lead to successful treatment of spasticity when you're using botulinum toxins. Number one, you need to be sure that you understand what the problem is. Number two, you need to understand what the source of the problem is. And I'm referring now at the muscle level. Number three, you need to dose appropriately the muscle. So use the doses that are recommended. Number four, be sure that you're putting your needle in the muscle. And then, I know that sounds silly, but if you're thinking about injecting the flexor hallus as long as the flexor digitorum communis and the tibialis posterior, those are three muscles that happen to be very close to each other. So you wanna be sure that you're where you want to be. And so using localization really makes a difference. And then the fifth item is be sure that the patient does some post-injection rehabilitation. That's an important element. So I always say that learning to inject is very simple because that's grabbing a needle and putting it in a patient. But learning to inject correctly takes a lot more effort. And thinking about why you are injecting is the part that takes the most work. And when I teach about management of spasticity, it's not about the injection, it's about why we are injecting and what do we want to achieve. So I hope I answered your question. And I think I look at this as an opportunity as well because the academy has made extensive progress in publications regarding the spasticity world. And if there's a way that we can lead efforts in advocacy and education, especially in the rubric of a post-treatment rehabilitation paradigm, we can certainly lead the way and help patients around the world. And I would just say that for those who are here and may not be aware, the academy created the STEP Spasticity Program. It's an incredible training program. It's very intensive and it's worked very well for those that have attended and participated in it. Dr. Patel. Yeah, just a question and a comment. First, on the GAST-T score, leg score, was that something we already had the GAST score and then minimized it and looked at just the leg part? Is that what that was? Yeah, so it's really focused on the lower leg. Yeah, so I know in full transparency, I was part of the study and had quite a few patients in the abolished study. And then the last thing I was gonna just say was just- So why are you asking the question about the GAST? You know, you knew that. Because you told me to ask a question. Oh, there you go. Thank you. Thank you for that. I appreciate it. But I'll add a comment. I mean, I'm just saying that this was kind of real world experience. And I think this matches with what we see. Some of us were treating a lot of these patients for a long time. Yes, there is improvement with repeated treatments and doing all that. So thank you. And thank you for having been one of those collaborators, even if you were not listed in the original article. So I appreciate that. Thank you very much. Thank you to all. Thank you. Thank you. Okay, so this is a completely random order. I apologize if any of you had your eyes up on going next, but we're going to welcome Kevin Pacheco-Barrios to the stage. Is Kevin here? Kevin is not here. Is anybody else representing the study comparative effectiveness of neuromodulation and exercise in fibromyalgia? Sensing none. All right. So we are now going Uh, Swetha Mukhabad... I'm sorry. I just... That's okay. I don't even want to attempt it. Um, Mukhabadi... Mukhabadia. Mukhabadia. Yes. Okay. I don't want to tell my puppy how to pronounce it. I agree. Uh, so welcome. Uh, and um, she's going to tell us about platelet concentration and platelet-rich plasma injection for carpal tunnel syndrome, a systematic review and pooled analysis. Oh, OK. Oh, yeah. It is easier, definitely, to see it from here. So hello, everyone. My name is Shweta Mukhopadhyay. I am a fourth-year medical student from Rowan in New Jersey. And I am co-author as well as presenter for our project here, Platelet Concentration in Platelet-Rich Plasma Injections for Carpal Tunnel Syndrome, which is a systematic review and pooled analysis. I do want to give credit to the other contributors as well. Tanya Israel, she is co-author, and as well as Musa Dali. He is another co-author. And Dr. Alta Mishraja, he is our PI as well as the APD for the Inspira Pumanar Program. So yes, without further ado. that's not supposed to be blank. Let's see. Are you having more success on your end over there by any chance? Thank you! Yay! Okay, I have no financial disclosures, too. Alrighty, so I will not belabor the point too much about what carpal tunnel syndrome is and what PRP is, but for just any uninitiated that happen to be in the room, carpal tunnel syndrome is a common intraparent neuropathy, usually in the median nerve distribution within the carpal tunnel, and there are many, many treatments for carpal tunnel syndrome, and one of those being platelet-rich plasma injections. Platelet-rich plasma is where we take a patient's own blood and we concentrate the platelets within that blood and we inject it back into the patient. And we do this because we hope that the growth factors that platelets release, they will promote angiogenesis, they'll promote cellular proliferation, and we hope that this will also help musculoskeletal injury recovery as well. Alrighty, and then with that being said, though, we do recognize that with PRP, there are a lot of outcome variabilities, and this is attributed to the fact that there's a lot of variation in PRP preparation variability, as well as administration variability. People use different systems, people inject in different ways, people use different EMG ultrasound, they just go in blind, a lot of different variation there, so that can also contribute to variability. We seek to at least alleviate that variability by looking at whether platelet concentration affects PRP outcomes, specifically for carpal tunnel syndrome. Okay, then just to go into our methods very quickly, so over here we went through multiple different databases, PubMed, Scopus, Embase, Cochrane Library, as well as ScienceDirect, and our inclusion criteria was as simple as any primary data, so control trials as well as cohort studies with a PRP treatment arm. Our exclusion criteria, if a study simply lacked data on platelets, if we couldn't surmise it from the lab manual, we simply didn't include it, and if our outcome of interest was not available, we also just didn't include that. Our outcome of interest specifically is the symptom severity scale as well as the functional status scale in the Boston carpal tunnel questionnaire. We use this at the pretreatment as well as three months or end of study for gauging our treatment outcomes. Alrighty, okay, as far as our included studies, so we did put a search string into the databases and then we came out with a lot of studies, about 3,000, but after a lot of duplicate removal after study appraisal, we did end up having seven studies to include, and within that, the total number of patients that we did align with was 199, and then we categorized these patients as falling in either high platelet concentration or low platelet concentration, so if a patient was injected with PRP with the platelet concentration five times above baseline, we would consider that high, and then if it was below five times baseline, we would consider that low. This number was specifically guided to us by a historical study about PRP injections, and they used the five times baseline as their marker, and then we had about 35 patients that were categorized into high concentration, and then 164 patients that were categorized into low concentration. Alrighty, so the meat and potatoes of it all. So we have two figures here. The top figure is the symptom severity scale, and then the FSS figure three is our functional severity scale. Ultimately, what we found was that a low platelet PRP, our pooled effect size was found to be 6.66, and then the high platelet PRP for symptom severity was 1.285, and then for our functional severity, then that was found to be with a low platelet of 4.936, and then a high platelet PRP was found to be 0.334. Just to go into the interpretation of this a little bit, so as we can see with symptom severity, an effect size of 6.66 is pretty high, and then we do want to say that a high platelet PRP of effect size 1.285, that's also very high, and then generally we consider about one to be like a good benchmark for whether something is effective, and then ultimately from this data, we concluded that a low platelet PRP yielded a greater symptom reduction, as well as just functional improvement for high platelet PRP. That being said though, both low platelet and high platelet PRP, they both resulted in significant symptom severity reduction in comparison to functional status. All of this being said though, there are some limitations for our review. We did have limited primary data. As you guys saw, we had seven studies included in our data, and there is variation in the protocol. So we were looking at platelets, but these people who were injecting, they used different methods. They used ultrasound, EMG. Some didn't use any of these methods to localize, so there is that factor to play, and there also was a low platelet data skew, so perhaps if there was more high platelet concentration data out there, then results may have also been slightly different, but of course with our conclusion, just from the data that we have been able to conclude here, low platelet PRP seems to be the optimal concentration for symptom reduction as well as functional status, at least as far as carpal tunnel syndrome is concerned, but for our future directions, we do hope that there'll be more research into PRP-injected materials, not just platelets, leukocytes for example, and just other research into confounding factors, injection technique, patient population. These are other things that we can look into that will hopefully help us standardize PRP, and then just help us get more consistent outcomes for our patients. Well, thank you for your presentation. Without intentionally putting you on the spot, can you comment on perhaps the pathophysiology of why low versus high would make a difference? Oh yes, so we had some theories about this, and we thought that perhaps with a high platelet concentration, perhaps there was an excessive inflammatory effect going on, and then that is why we concluded that perhaps low concentration is just the better way to go about things. I have a comment and a question. The comment is, I'm very impressed. You did a terrific job, you know, for a medical student to put this presentation together. I congratulate you for that, and I hope you're applying to a good residency training program, including MOSRI. Yes, I will. I just, you know, put a plug for that. The second is, you didn't talk about the volume in itself, and if the volume of fluid injected may have made a difference. Yes, you're absolutely right. We didn't talk about that. That is data that we initially included in our, like, big data gathering, but ultimately we didn't include in our analysis, and you're absolutely right that that could have also affected outcomes as well. I don't have the answer as far as what that effect would have been, but that sounds like a good topic for another research project. Thank you for your presentation. Carpal tunnel is a very common entrapment neuropathy, and can you, did you find anything in the literature or in your own experience, what, how does this entrapment neuropathy get better with injection with PRP? So, yeah, absolutely. So, I thought that this was twofold. So, on one hand, they believe the common thought process for PRP alleviating musculoskeletal injuries is just helping promote angiogenesis vis-a-vis the platelet growth factors, and cellular perforation helping inflammation. However, I also believe that there was just a simple, like, as simple as, like, a space increasing effect with volume as far as carpal tunnel syndrome, because with, like you just said, carpal tunnel syndrome is an entrapment neuropathy, and then when we inject material inside of the carpal tunnel, I thought it was just as simple as just increasing the space so that you're decreasing the compression and decreasing the entrapment. So, I think it's a twofold, like, treatment process as far as that goes. I hope that answers the question. Thank you. All right, is Tanya Israel here? I'm so sorry, so she's the co-author for my project. I think she just got in love with it. I see, okay. Who's in the room that was intending to present? Atul Patel. Atul Patel, please come to the stage. I apologize, there are multiple forms of... No, no, you're good, you're good. All right. Look, we're doing this as best as we can. Have fun. Yep, exactly. And this is the one for advancing, right? This one right here. The little arrow. Oh yeah, arrow, there we go. Okay. It's morning still, right? Good morning, everyone. And I'm gonna be presenting on DAXify. I'm gonna be talking about the efficacy remaining at time of requester re-treatment following botulinum toxin treatment for cervical dystonia. And this could be a potential for a new treatment paradigm with DAXy botulinum toxin A. I'd like to thank my co-authors, Robert Hauser, Peter McAllister, Todd Gross, Rashid Kazrouni, and Connor Gallagher, and David Hollander. Okay. These are our disclosures, so if you wanna take a photo. All right. So introduction, just talk to you a little bit about cervical dystonia, the treatment. Botulinum toxin is the treatment of choice for cervical dystonia, right? And we know that the symptoms are well-controlled with repeated treatment. These patients require treatment every certain interval. And currently, with the insurance and the way that things are set up, and with the previous studies, with the existing botulinum toxins, patients receive treatment as early as 12 weeks after their previous treatment. But what patients do say, and studies have shown this, that many patients start noticing a decrement in their therapeutic efficacy as early as eight to 10 weeks after their treatment. And so what happens is that these patients then have issues with initial improvement, but then they start losing function and efficacy of the treatment until it's time for the next treatment. And so there's a gap up there where they're not getting adequately controlled, the symptoms aren't adequately controlled. The most common symptom is pain, but other than that is also movement associated with cervical dystonia that the treatment actually helps with. And then, as I alluded to, the current FDA product labeling and reimbursement practice limit the minimum treatment interval to 12 weeks, so you cannot inject any sooner than 12 weeks with the current treatments out there. Dioxibotulinum toxin A, also known as Dioxify, is a newly approved botulinum toxin, neurotoxin A, and it is a product with a novel formulation that contains a custom-engineered peptide, which is referred to as the RTP004. And this has shown extended duration of symptom control in multiple studies as well, including not only in cervical dystonia, but other uses of that product in different conditions. The objective of this study was to study, assess the residual therapeutic efficacy of BOND, a botulinum toxin injection, at the patient-desired re-treatment interval cervical dystonia... Desired re-treatment interval in cervical dystonia. And so what we did was, the methods was, we did some post hoc analysis of a study that was done, ASPEN-1, and then there was a follow-up study called ASPEN-OLS, Open Label Study. So these patients, in the study, had two options for re-treatment. One option was that they have lost 80% of the maximum improvement that they had, measured by a score called TWISTERS, which is the Toronto Western Spasmodic Total Cholesterol Rating Scale. But the patients also had the option of asking re-treatments before they had reached the 80% decrement in the study, and that was based on the patient's request and the PI's judgment that they were appropriate to be re-treated. So there was a group of patients who received treatment before they had 80% decrement, as measured by the TWISTERS score. What happened here? Sorry about that. Okay. And what we found, what we looked at was that the median percentage of efficacy remaining was determined using the TWISTERS score. So that's a scale that's used to measure cervical dystonia, and if they reached a loss of 80% or less. And then the estimate of percentage of efficacy remaining at the preferred injection. So instead of the 80, the people who were coming in and getting treated before they had lost 80%, what was their percentage of efficacy still left, as measured by the TWISTERS score? So this is, again, post hoc analysis, looking back at this data. Results. So this is what we found. There was a substantial proportion of patients in Aspirin 1 and the open label that were re-treated with greater than 20% efficacy remaining, right? So that was the one thing. And what we found was that 28 or almost 30% of the 1,175 re-treatments with DAXC had more than 20% efficacy still remaining at the time of re-treatment. Then nearly 50% of peak efficacy remained at the time of requested pre-treatment, a re-treatment, right? So these patients who were asking for it earlier, or about 50% efficacy was still there based on the measurement by TWISTERS score. Among all the Aspirin patients, it took 16 to 17 weeks to lose about 50% of peak efficacy. So we went back and looked at when was the 50% peak efficacy and the timing of that, and that was around 16 to 17 weeks. And that the patients who were requesting re-treatment with more than 20% efficacy remaining had more modest titrations. They did not require as high a change in their dose with re-treatment as patients who waited till they went all the way to the 80% loss of efficacy. Looking at other indicators and things like that, dysphagia and muscle weakness rates were low across all re-treatment scenarios. And then this graph kind of shows that because there were two doses, right? There was the 125 and 250 unit, and then you can see up here, this is the 20% efficacy remaining was around 20 to 24 weeks. When you look at the 48% efficacy remained median, this was the median for this group of patients that was around the 16 to 17 weeks. So conclusions, these findings demonstrate that about 50% efficacy remained in patients who requested re-injection before returning close to baseline status. Adverse event rates remained low across all re-treatment scenarios. Among all patients treated with DAXI, median time to lose 50% of peak efficacy was about 16 to 17 weeks. And while duration of efficacy defined as loss of 80% of peak treatment benefit may be valuable for understanding doing studies, in the real world, people don't wanna wait till almost all the effect is gone before they get re-treated. So obviously it makes sense clinically that they want to come back and be treated before the effect of the medication has worn off. And the extended symptom control observed with DAXI allows physicians the flexibility to treat at patient's desired re-treatment intervals and optimize to each individual patient while still remaining aligned with the FDA. Because if this thing is lasting longer and allowing the patient to be treated after a 12-week period and insurance is only allowing 12 weeks, this gives you another way to treat these patients by controlling their efficacy and decreasing their response before it has worn off to the point that it's close to baseline. Thank you. Dr. Patel, thank you very much. That's a lovely study. I do have some concerns in the way you're presenting the data and maybe you can try to explain it to us. If you look at the premise that patients went to ask for their re-treatment and were not treated, why did they go back to ask for the re-treatment? You know, I hear your twister was still within reasonable improvement, but the patients came and asked. Right. So the way the study was designed was after you get treated, you are monitored and then the one criteria for re-treatment was to wait until the twister score had gone down to 80% decrement, right? So if the patient didn't ask for it, then that was the criteria to re-inject. That's not the way it was presented. Oh, did I mispresent it? No. I don't know if you mispresented it, but that's not the way, at least it sounded to me. No, so that was it. And then the second criteria was if the patient said, I want to be treated before I reach that point, because it might be more than... It's definitely more than 12 weeks, but it could be at week 16 or 17 or 20 that, hey, I don't want to wait till I'm 80%. I need it now. Then if the PI agreed to it and made sense, then they got re-treated. The other piece that is confusing is you had two doses. Correct. In a placebo. Yes. And when you look at the high dose, actually performed worse. Correct. So does that mean that more is not better? One. Two, if you could tell us, your placebo curve looks a lot like your active curve, except that this patient's perceived that they got better even with placebo. Great questions. So there is the effect of placebo is becoming a bigger and bigger issue with all of these studies. Patients are having more and more. So there is a therapeutic benefit, quote unquote, when just seeing a patient and when they're in a study, expectations and all this. I think that's happening with, I do quite a few clinical trials and we're seeing this placebo creep in most of these patients. But there is a significant differentiation between the placebo effect and the two doses. This was an overall not that big a study and that kind of concerned us. Why is a lower dose doing a better job than a higher dose? Does that really answer the question? So if you look at the numbers and everything, not necessarily, and this has also happened in some other studies where sometimes the lower dose looked better than the higher dose. So I think it's more a statistical thing and not necessarily truly indicating that a lower dose is better than a higher dose. Subsequent studies and subsequent observations have shown that higher doses seem to have a greater impact than the lower doses. Great, go ahead. Obviously this is a pivotal trial and I believe that there's been further analysis done in real world experience. I'm assuming you've continued with this. In your experience and the colleagues participating in this thing, in their own hands without the confines of a pivotal trial, are you seeing the same therapeutic duration or are you seeing a different effect of that? Great question. So yeah, we're still learning about this and I do have quite a few patients that I'm treating and also we had another project we did which was called the preview program where we looked at other patients. But really it is looking like it's not all patients, it's not working the same exactly for every patient. The patients are now more satisfied around the 12 weeks but they're getting a better outcome and they're happy going every three months and there's a cohort of patients that are starting to go, in my own experience but also in the preview, around the 16 to 18 week timeframe where they are happy at that point and now not coming in as frequently for treatment. And then there's some outliers, some people who want it sooner of course and then there's also a group of patients that are going way longer and it's really interesting to look at the characteristics and see what happens with that. Thank you. Go ahead. So one comment and a question. I think my comment is I don't think anybody should forget the irony of repeatedly hearing the Twister score from a study in Kansas. So kudos to you. But more importantly, in stretching out the effects, is there an opportunity for a rehabilitative paradigm, PT or OT to get in there as well? Great comments here. Number one, I am trying to put Kansas City on the map. People keep asking. With Twisters, you might end up not having it. Maybe not with that but I am trying to be the person staying in Kansas City and doing this thing and making people think about that place instead of the East Coast and the West Coast most of the time, right? So thank you for that comment. And then the other one was, yes, I think there is a huge opportunity to look at all those other things and I think as rehab physicians, we're in the right position to help these patients because it's not just the botulinum toxin treatment alone. It is all the other things, stretching out the contracted muscles, strengthening the weakened muscles, helping with the postures, helping with the activities of daily living and function. So we bring that to the table that unfortunately our colleagues in neurology don't even get training on. So that's a big gap. Thank you for pointing that out. So I have to make just one more comment and that is that I congratulate you because if you look at the list of all of those presenters or all of your colleagues, they're all neurologists. And so having a physiatrist represented in the treatment of this population is my kudos to you for doing that. Thank you for recognizing that. Thank you.

scientific research

abobotulinum toxin

lower limb spasticity

platelet-rich plasma

carpal tunnel syndrome

DAXI botulinum toxin

cervical dystonia

physical medicine