I am a pain subspecialist at Brown and I welcome all of you. I apologize for starting a few minutes late. We have a little bit of a discrepancy in the schedules that were given to us, so unfortunately I don't have the lineup of the presenters with the actual title of their abstract, so I apologize in advance. So I'm just going to, we're going to do things a little bit backwards. But moving forward, it's important to highlight the fact that there were over 1,000 abstracts submitted or 1,100 abstracts submitted for this year's meeting, and the sessions that we will be having over the next three days are highlighting the best of the abstracts that we submitted. And so we're really enjoy, we really feel fortunate to have had the opportunity to welcome this many scientific abstracts into our academy. We're really trying intentionally to grow the scientific component of what the academy is presenting, but also on behalf of the specialty so that it's more scientifically driven to help drive the growth of what we do. So thank you all for your academic contributions. So this year, we're going to start with Dr. Connick, did I pronounce it right? Okay, so Rosalind Connick, who's from the University of Florida, Dr. Rosalind Connick, excuse me, University of Florida College of Medicine PM&R program, welcome. Thank you very much for the honor of presenting today and for this great opportunity. So today I'm going to talk about the decline in Medicare reimbursement for outpatient procedures in physical medicine and rehab from 2010 to 2024. So as you all know, in the US, the healthcare costs continue to rise, and since the 1960s, it's about 18% of the gross domestic product today. Procedure-based healthcare is moving into value-based healthcare, and then Medicare re-evaluates reimbursement rates annually and then adjusts the Medicare physician fee schedule to maintain budget neutrality. You've probably gotten these emails from the AMA, from the academy, where, hey, reimbursements are going down, do something about it. And then physician service reimbursements for procedures, office visits, and anesthesia are kind of continually going down in all the procedural and surgical specialties. There's a lot of literature in the ortho, but in PM&R, not as much. So this is what I wanted to tackle. So my objective was to evaluate the trends in Medicare reimbursement for some of these common outpatient procedures in PM&R from 2010 to 2024. So methods, I used the CPT codes from the Medicare coverage data set. I used some of the CPT codes that we as residents kind of pull in and log our cases with. So we looked at EMG and nerve conduction studies, injections for spasticity management, musculoskeletal injections, and spine procedures. And then I pulled that using the physician fee schedule lookup tool. Now, you all know the value of the dollar has changed a lot. So I adjusted to the inflation for 2024 values using the consumer price index from the US Department of Labor Bureau labor of statistics. And then I also calculated this compound annual growth rate. It is used a lot in economic literature, basically looks at the annual rate of change, and that's the formula for it. So talk about EMGs first. We'll deal with the good news. So the EMG and nerve conduction study reimbursement from 2012 to 2024, it seems like there was a boost between 2023 and 2024 in the values. So overall, across the EMG codes, there was a 56.94% increase, and the CAGR went up to 7.28. Now, the other question is like RVU value-wise. So as you'll see, RVU values didn't really change much. So this 95886 code went from 0.61 to 0.57 for the RVUs. None of the other ones changed. All right, spasticity-wise, things are kind of going down. So overall, across the spasticity codes, there was a 5.42% decrease, and the annual growth rate hasn't really changed much. For MSK procedures from 2010 to 2024, it's also coming down slightly. So like a 33% decrease overall, like calculating all of these. And then CAGR was negative 2% calculated, and those were the MSK reimbursement codes in case you do a particular one and you're interested in looking it up. And then as far as spine procedures, overall, there was a 34.6% decrease, and the CAGR went down by 2.4, as you can see here. And then as far as this is one of the ones where RVU values changed, very non-significant change, though, for the 27096 code, which is the SI joint injection, and the 64479 code, which is the cervical-slash-thoracic transforaminal injection. So in conclusion, kind of reimbursement across all the codes has increased significantly between 2010 and 2024. Mostly it was in the 2021 and the 2024 era. RVU changes, if there were any for this, were minimal, and all of these things are kind of important for us to know to either maintain a viable practice, to know what is going on, and to know what to advocate for in the future, so thank you. I just want to applaud you for this type of work, because I think not enough of the PM&R community looks at the financial side of what we do, and that's how we grow, and that's how we advocate for ourselves. So what words of wisdom do you have based on the data that you collected for the academy at large in efforts to advocate for what we do? You know, that is an excellent question. So I am currently involved with the AMA as the RFS liaison. I work with Dr. Hubbell, Dr. Grierson, and they work closely with the RUC, and that's one way to get involved. Now there's also involvement at state levels that, you know, should not be discounted, so with your, we're in, I'm in Florida, so Florida Medical Association and some of those other ones as well, so that's one way to handle it. And then, you know, I'm a big proponent of thinking about, you know, not just whining about things, but, you know, kind of trying to affect change. So one step is knowing that this data is out there, knowing what are the values, and then how, what do we think the values of these things should be, and we need to work together to do that, because let's face it, you know, as a pain physician, how much, you know, do you know about EMG and how long it takes? You forget over time, you know, so. We're a broad specialty, and we can easily forget what each of us does, and I think it's important that we're aware. What suggestions do you have for the folk in the room who are in early training or even in medical school as to how to get involved? So we have this lovely opportunity of the AMA RFS, like, FIT Council position. The other way is to get involved with your state medical society and get involved with the RFS that way and through the AMA. You can also do great work at a state level, so the state medical specialties, and then there's this phenomenal, you know, even, I'm in Alachua County. There are county, like, medical associations as well that you can join and kind of start your way up, because it's a very convoluted process, and I learned so much in this role that, you know, you have to be in it to understand how these things are accomplished. Yeah, indeed. I just want to point out that it's important to understand that national coverage determinations are different than LCDs or local coverage determinations in your area, and there's a lot to learn, so it's really important when you establish your practice or wherever you are to learn what's going on in your neighborhood, so to speak. Any questions from the audience or comments? I don't think this travels. I'm sorry, I'll speak loud. Okay. Oh, right behind you. From Mayo Clinic in Jacksonville. Great work. I think even more important, as you've alluded to, in addition to just the change in revenue is the access, and with the last three and a half years or so with the LCDs and NCDs that are coming out, they could pay us more, but we're going to get reimbursed less because our patients are being denied care on that basis. So I'd love to see another follow-up over time how access to care based on some of those issues pans out in the last five to 10 years, but it's really dropping off. Thank you. Is there any questions there? Hi, Linda Gomez, Finland. So I'm just wondering, since PM&R does add so much value to patients' lives with improved quality of life and function, I'm just wondering with this value-based care, is there a way to highlight what PM&R does and what PM&R physicians do so that you can overall increase reimbursement to make it match what PM&R does for patients? Excellent question. I'd love to hear your thoughts. So I want to say what over the last five to 10 years, the Academy has really put in a lot of work and specialty brand expansion in trying to make the voice of physiatry better known, and we see that in, I think, the increase in medical student applicants. We see that that way, but there's still a lot more work to be done in the sense of I was reading people's letters of rec, and people would write preventive medicine and rehabilitation. So people are still not quite aware. So there's still more work to be done in that sense, and obviously working with congressmen, potentially in the Senate, directly to raise awareness. Thank you so much. Okay, so moving on, we have Mengdong He, did I pronounce it right? Yes. Okay. From UCLA, David Geffen School of Medicine, welcome. Thank you. Good morning everyone. My name is Mengdong. I'm a fourth year medical student at UCLA. I'm delighted to present my project titled National Trends in Use of Rehabilitation Services Among Older Adults in the U.S. Between 2015 to 2022. Before I start it, I would like to thank my co-authors listed below my name at the University of Pennsylvania for their mentorship. I have no disclosures. So currently, there is limited national data categorizing the utilization trend of rehabilitation services among older adults in the U.S. Therefore, the objective of this study is to evaluate the trends, sorry, trends in the use of rehabilitation services and patient-reported functional outcomes in older Americans. We use the data called National Health and Aging Trends Study, or NHS, between 2015 to 2022. So NHS is a national survey of a sample of representative Medicare beneficiaries that The goal of the survey is to assess the health needs of aging Americans through standardized in-person interviews and physical performance assessments. In terms of analysis and study design, we conducted a repeated cross-sectional study. In our cohort, we included individuals who age 70 or older and who are alive at the time of the interview. Our primary outcome were patient-reported use of rehabilitation services in the 12 months before the interview and their associated functional outcomes. So we identified a total of 39,967 responses from 10,086 unique respondents over the study period. 22% of the study responses reported use of rehabilitation services in the year before the interview. Of those who used rehabilitation services, 60% were between 70 to 80 years, 61% were female, and 84% were non-Hispanic white, 6% black, 6% Hispanic, and 3% Asian. The main reason for patients receiving rehabilitation outcomes not reported here are rehabilitation due to post-surgery recovery, accounting for 30% of the responses, and non-surgical MSK conditions for 43%. So, overall, the use of rehabilitation services during the study period increased from 20% to 25%. Overall, we can see an increasing trend, except there is a dip in 2022 that coincided with the COVID pandemic. Among those who used rehabilitation services, there is an overall decline in the use of inpatient and home-based rehabilitation care. Specifically, inpatient rehabilitation use reduced from 34% down to 24%, and home-based rehabilitation use reduced from 40% to 35%. In contrast, the use of outpatient rehabilitation services increased from 65% to 75% over the study period. Again, looking at those who used rehabilitation, we examined their reported functional outcomes. So, this graph shows the functional changes after their rehabilitation care. And we can see here, there is a slight increase of percentage of respondents endorsing functional improvement from a 70%, sorry, this slide, increasing from 70% to 72%. This is a closer look at those who reported improvement in their function. And we can see a relatively stable trend over the study period, around 40% endorsing a high level of improvement. So, in conclusion, utilization of rehabilitation services among older adults increased from 2015 to 2020. This is mainly driven by the increased use of outpatient services. Patient-reported functional improvement also increased over time, with 40% indicating a high-level improvement. These trends help establish baseline care utilization patterns and lend support to the value of community-based rehabilitation services for improving overall function for older Americans living with disabilities. And the main limitation of the study was patient-reported measures that are known prone to recall bias. However, they have been validated by enhanced study team with high sensitivity and specificity and PPV and NPV ranging between 77% to 95%. So, for next step, we're planning to look at granular data, stratify the trends by patient demographics such as race, socioeconomic status, test the difference between those groups, and also identify patient-related factors associated with rehabilitation use. Thank you very much for your attention. Thank you. That was, again, very applicable and practical abstract that I enjoyed reading. I just wanted to question, is the dramatic drop in inpatient, does it differentiate between sort of inpatient SNF or is this just inpatient acute rehab? So, that is another limitation of the study. Unfortunately, in this survey, they don't really differentiate SNF versus acute rehab. We actually digged into it and it turned out we couldn't really. So, in the next step, we're trying to figure out maybe there are some qualifying conditions for ARU and then we'll see if we can find anything there. I think it's really important to follow up on that because, as we know, the functional outcomes from SNF are gonna be very different than acute rehab. And I'm just wondering how much of the decrease in inpatient utilization can be correlated to the insurance authorization issues that we're all facing in inpatient PM&R. Did you get any insight into that, how much it was based on just denials? Yeah, so that's another limitation of the current data set, but not for NHS as a whole because NHS is a survey but can be linked to Medicare. So, I think that's something worth exploring to see if Medicare claims would have data on the rejection to rehab. And if that's something available, I think that would be very interesting to see. Yeah, it's a great starting point. And you could make yourself very busy with follow-up studies and trying to assess the granularity. So, thank you. Any questions or comments from the audience? Sensing none. Thank you. Thank you very much. Applause So I apologize we're all working from different lists at the Academy here, so I apparently skipped someone All right what I I think I skipped a bunch of people so We're next going to welcome dr. De Jesus from University of Puerto Rico Good Morning everyone pleasure to be here I'm a PYT resident at the University of Puerto Rico And I'm going to be sharing our experience with the PM&R consultation service in our trauma unit So a little bit of background based on the nature of a trauma unit they tend to Give care to a high volume of patients with polytrauma multiple injuries And I don't think I have to convince you that we are well equipped as physiatrists to take care of those patients with severe injuries complex cases and looking at it from a bio-psycho social perspective but despite our Contributions that we can make to some of the cases there is lack of access to PM&R facilities in trauma units and acute care hospitals as a whole there's some information about international healthcare organizations about this car city or short availability of rehab doctors compared compared to Population size and this is even more highlighted in the rural zones where there's even less physiatrists available for these patients obviously some of the challenges that patients face when being discharged is We have policemen when they they have issues when they're gonna be sure the patients to inpatient facilities or sniff and Probably it has to do with that gap and that low availability of PM&Rs. So There's been data published about the benefits of a PM&R services and how they can reduce the line of state of patients improve outcomes And how we can contribute to that coordination on discharge From those patients So based on that information, what do I what do we be hypothesized that a full-time PM&R service consultation service in a trauma unit can decrease the length of stays of patients and The consultants patients to our service are going to be more complex and this was a retrospective medical record review in our trauma center in PR That Included every adult age patient that was admitted due to a traumatic injury in our facility So we look at two groups The patients that got a PM&R consult and patient that did not receive a PM&R service and we look at several outcomes length of stay time to consultation injuries of various core and the volume of so The consultations that we got through two time periods. So the first time period we'd have a part-time Consultation service that was led by residents obviously under the guidance of a PM&R attending and then on the second time period there was a Brain injury board certified PM&R attending that was hired by the trauma unit that was there full-time working with them So this is what we saw There was an increase between the two time periods On the patients that were admitted and were consulted from a 15.3 percent to 25 percent Which is an absolute increase of 9.7 percent of the patients that were consulted in the unit There was a decrease from the time that the patient was admitted to the consult to PM&R from three weeks up to approximately a little bit less than two weeks and Based on the patient characteristic. We can see three main Observations we can see that in the first and the second the patient consulted to PM&R, which is in gray They're older patients. We can see the diameter of this bubble chart that the diameter is a little bit Wider, which means that there's a higher injury severity score, which is what this number represents so patients consulted to PM&R had a Polytrauma more complex cases that does that were not consulted which makes sense And then from the first time period to the second time period we can see that the age increases as well In terms of the line of stay we can see in the solid lines That in here in gray This were the patients consulted to PM&R and there was a 10-day decrease in the level of stays of PM&R consulted patients In comparison to this solid line, which is the non consulted patients We basically stay the same we can see with linear regression analysis that Correct for age sex and other variables that we can see the same Outcomes a decrease in the benefits of the patients that were admitted So how does this information in context with the current literature? Some patients of the general population have some issues understanding what PM&R does and so does our peers in some specialties So there's information that there's a lack of clarity about what a PM&R does and there's a variation of the expertise of the Physiatrists are in care of in acute care facilities and both in trauma that we need to define a little bit better There's some information that these ideas should lead this post acute care planning and the short planning and should be involved in patient care, but there are some mixed outcomes in how PM&R consultations have positive or little impact on patient care. So what we can take home from our study is that in in our study a full-time PM&R consultation service that was available in a trauma unit reduced the line of stays of the patients admitted to that unit there's More work that we need to do in defining the PM&R role in this Spaces and there's gonna be a shortfall or a shortage of physiatrists beyond 2030. So we need to keep investing in programs like the ones that we have in a PM&R for medical students and residents to keep growing the role and Our contributions that we can make to patient care That's it, thank you Fascinating data. Thank you. I'm just curious if you think that the results that you had would still apply for The complexity of cases maybe in a level one trauma center. Yeah, absolutely. I think is they're gonna be the same I think that that face-to-face that PM&R has being all the time in concept with the trauma and the PCPs that are taking care of patients They tend to consult more they tend to like engage more with PM&R and that's across all the spectrum in all units Visibility is key and Do you have any data that you could? Draw on for things like reduction of falls or medication errors or things with complex PM&R acute patients patient cohorts that the primary service doesn't Manage as well as we do Anything that you can glean from those or even readmission rates that could be helpful Our unit is looking into those like as future projects, but not for this project per se But we have quality improvement projects that are looking into that Great again a lot to build on. Yes data set any questions or comments from the audience. I Just wanted to add this is a great segue from the other projects that we have I was the specialty brand expansion resident liaison. So I think there's a lot of work being done Promoting the specialty with CEOs The C suites all the stuff and I think that's really important So we need to be advocates just like you said ambassadors for our specialty That's important as you can see there's a trend and sort of the discussions that we're having this morning for a reason Okay. Well, thank you. Thank you so much Okay, we're going to welcome Nicole Berlisky I hope I pronounce it. Okay from Icon School of Medicine outside a PM&R All right, hello everybody, I'm Dr. Borilsky, this is Dr. Shulman. As you can see, some of our other co-authors on this study, we worked very closely with the liver transplant team at our institution, and so we wanted to thank them for their assistance with this as well. So, liver transplantation in our patient population in general is, the need is on the rise, and unfortunately the supply is not matching that. So what we have been seeing is, patients are requiring higher MELDs to become the ones who are eligible for a transplant, and to actually obtain that transplant. MELDs, for those who are not familiar, are a score that transplant physicians use to identify the severity of a patient's liver injury, and it includes different components like sodium level, creatinine, INR, bilirubin levels. And so this patient population in general is very sick, and at very high rate for readmission, even after the transplantation. And so, we wanted to see, identify how the discharge location impacts the readmission rate. So, we wanted to see if research regarding discharge to an inpatient rehabilitation facility, versus discharge home, how that impacted liver transplant care. So at Mount Sinai, we're a large tertiary referral center. We get a lot of transplantations, especially for liver patients. And in our retrospective chart review, we identified 146 patients. 74 were part of the acute inpatient rehab facility, discharged to that location group, and then 72 were discharged home. We collected demographic data. We also wanted to identify the baseline illness severity, and for that we used the MELD scores prior to their liver transplantation. We also looked at KPS and FIMRI. We looked at five-year mortality rate, and our primary outcome was readmission rate following liver transplantation. So, looking at some of the data, this is the big table from what we did. I wanna turn your eye to kind of the light blue. Our primary outcome was number of patients readmitted to the hospital. That's what RH stands for. We also looked at number of deceased participants. What we see is number of readmitted patients. Those going home were admitted at a higher rate than those going to acute inpatient rehab, 15 versus 23, which is a 12% decrease in readmissions. If you do look at our p-value on chi-square testing, it is non-significant. And then the next thing we looked at was number of patients who unfortunately passed our mortality rate. And what we do see is patients going home were passing away at a higher rate, about 5% higher, six versus nine patients. Again, when we ran the chi-square test, it's non-statistically significant data. The other thing we ended up looking at was we created a linear regression to try to predict factors in these liver patients that could predict if they're gonna be readmitted to the hospital or not. What we found is, of all the different factors we studied, admission to IRF or not, inpatient rehab or not, is the only significant factor that predicted risk of readmission. So generalizing that data to kind of where are we going with this. First and foremost, looking at readmission rates. We saw a non-statistically significant, but most likely clinically significant, decrease in readmission of patients admitted to acute rehab. 12%'s pretty high when we're looking at patient care data. Next, we looked at acceptance to acute rehab is the sole predictor of anything we looked at for readmission rates for these patients. And last, we found decreased mortality in these liver transplants. Again, not statistically significant, but we think quite clinically significant is a decrease in a 5% mortality ratio is pretty big when you're treating a very high volume of patients as we are at Sinai. So kind of generalizing the study for takeaways. Some advantages of sending these liver transplants to acute rehab. It's a higher level of care. You're being rounded on by a physician every day. There's 24-7 nursing care. There's really eyes always on you as a patient. Also, these facilities are more equipped to handle very complex liver transplant patients, especially because many of them have post-surgical complications. There's more intensive therapy going to an acute rehab as opposed to really anywhere else. And last, there's an interdisciplinary approach. These rehab teams are talking with these transplant teams. It's very easy to get the transplant teams back to the bedside if there's any mistake. And with the high level of monitoring of these patients, whether it's labs, physician check-ins, whatever, you can really get ahead of any of these liver patients getting sick. So some future directions for research. We would love to have some randomized controlled data. This was a retrospective study, but actually randomizing patients and seeing what the data looks like would be interesting. Next, we touched on the FIMS score, Functional Independence Measure. We would love to compare this score in the home group versus the acute rehab group. What we saw is the FIMS score got better in the rehab group, but we didn't compare it in the home group because we lost those patients to follow-up as they went home. So that would be really interesting data for us to dissect. Last, our sample size could definitely be increased, increase the power of our study. We could even include multiple different acute rehabs as we were looking at a pretty limited population of just 145 patients from the New York City area. So thank you so much. Thank you both. You bring up a good point at the end about the data and data collection and numbers. And it may be worth approaching the Academy and looking at a potential registry for this cohort of solid organ transplants that could be expanded upon. It could be a niche area within PM&R that we could grow, just something to keep in mind. In your data, do you have any sense of the generalizability of this to other solid organ transplants, like pancreas or kidney or anything like that? So although we can't make any assumptions based on our data because we were looking at a very specific pool of patients, you know, just liver transplants, I guess my intuition tells me that this is probably quite generalizable to all transplants. Just the idea that we send these relatively very sick patients to rehab where they're being rounded on by physicians every day. We're taking labs weekly. You know, they have a lot of eyes on them. It's very easy to get ahead and see any potential form, reasons that a patient could decompensate and kind of loop in the transplant teams. As opposed to someone who goes home and might not know what to be looking for, they might be presenting, you know, kind of once the snowball's gotten rolling and the patient's really too sick. Do either of you have any thoughts on the role of prehab in these patients to prepare them to be better candidates for the transplant and do better in acute rehab? I think that does bring up an interesting point. As we touched on briefly in our presentation, these patients are very sick before they get the transplant as well. And the transplant surgery is a very intensive surgery. So my intuition would as well be that they would definitely benefit from that, from a pre-rehabilitation program, whether whatever setting it's able to be offered in just to get them to as high of a functional status as they may be able to get to to better tolerate the surgery and avoid the subsequent complications as they're able. It may be worth, the reason I bring it up is we've developed a cancer rehab program and we're seeing that prehab for patients before they undergo stem cell or radiation or chemo can often do better in their functional metrics after they had that. Any comments or questions from the room? which means they're sicker, you know, usually, right? So, well, thank you for clarifying that. Just for my own edification, so how would you just, a patient could be waiting and literally they'll get a call and you're in the OR tomorrow, you know, what's the turnaround, okay. Okay, interesting. Any other comments or questions? Thank you both. Thank you. Thank you for having us. Okay, so we're now going to welcome Xiaowu Norman-Pan, I hope I said that right, from UT Southwestern. Oh, cool, someone is monitoring the laptop. Hi, everyone. Thank you for coming to this presentation. I'm Xiaowu Pan. I go by Norman. I'm right now a research instructor at University of Texas Southwestern Medical Center, Dallas, Texas. This research is done by the collaboration, by the collaborators listed above, and supervised by Dr. Nitin Jain from the Department of Physical Medicine and Rehabilitation at University of Michigan. And we are looking at the long-term outcome between surgical and non-surgical treatment for the patient with rotator cuff tears. So the rotator cuff tears are a leading cause of shoulder pain and disability. Treatment options including surgical repair, injection, and physical therapy. Choosing the appropriate treatment is often a patient-centered shared decision-making process that consider factors such as the age of the patient, the function demands of the patient, the patient's response to the first physical medicine trial, other factors including the severity and the cause of the tear. Generally speaking, younger patient with higher function demand or those with larger or complete traumatic rotator cuff tear are more likely to undergo the surgical repair. However, most existing evidence are based on short-term or middle-term outcome such as like between one or two year outcome. And there is limited, or we say insufficient evidence of the long-term outcome to support the shared decision-making process. This is our study design. Our study is a multi-center perspective cohort. We recruit 169 patients for age 45 and older with symptomatic rotator cuff tear from those three academic center and one community clinic. Patient were assigned to surgical group or non-surgical treatment. Basically it's a physical therapy based on their shared decision-making process. It is not randomized. And the outcome we are looking at is BADI and ACC score. Basically these two score are patient reported outcome that is validated with very good inter and intra reliability. Those scores focus on the domain of pain and function improvement. As of the statistic methods, we use inverse probability weighting to control for the baseline difference between treatment groups. And we use a generalized linear mixed model to account for the follow-up time. Let me show you how the inverse probability weighting work on this population. So sorry about the big table. This is a table one. It's going to list the patient demographics, the characteristics of the rotator cuff tear, and some MRI funding. What does the IP weighting do? So then we look at the green frame. There's two columns. What does the weighting do is to make the difference between group at the baseline, minimize the difference. What we can see is the p-value, some of the p-value is under 0.005, but after the weighting it went up and there's no difference between group. It's not a magic. It's still some like limitation I will discuss later, but here what we can see is that non-surgical group tends to be older, have fewer traumatic tears, higher baseline function. And this is our main results. On the left-hand side, we can see the crude distribution of the pain and function outcome, and we can see both treatment led to an improvement of pain and function, with the non-surgical group improved at a slower steady rate, while the surgical group improved at a faster rate. And on the right-hand side, the upper side, it's a result from the generalized linear mixed model, which account for the effect of time and the baseline characteristic as well. So the rate of the improvement is comparable in both group before 12 months. It's above the green line. We can see the p-value is not significant, so we say that the rate of improvement is comparable. And starting from one year, the surgical group shows faster, the rate of improvement is faster in the surgical group than the non-surgical group, and this benefit maintained over the five year. And I will also raise the discussion point here. The first discussion point we want to talk about is the timing of the follow-up. As I said, a lot of research focus on one-year or two-year outcome, and in our research, we do see there is a difference between different time point. So we suggest at least one-year follow-up is needed, and more research should focus on long-term outcome, because rotator cuff tear is not a short period of disease. It's more like a chronic condition that can impact your shoulder function, not just one or two years. Another discussion point is about the effector size. We can see over the five years, the effector size is around, the difference of the score is around like 10. It's 9.48 for spidey, and it's 12 for the ACEs. While I also listed the MCID, which is the minimal clinical important difference for both score, the MCID is also around 10 score. So what does that mean? Although there is statistical significance between groups, the benefit might be modest. It's not going to be beneficial for every patient. We need to look into what factors that we can better select the patient. Then we move into the predictors, so what kind of baseline characteristics the patient is going to have, going to predict a better outcome or more benefit from the surgery. So we tested a bunch of factors, used a technique called effector modifier. We added the effector modifier to the generalized model, and what we found is that older patients, people who aged 65 or older, they tend to benefit more from the surgery, while the patient with traumatic tear are also associated with better outcome from the surgery. One discussion point here is that for the elderly patient, we usually think that they won't benefit that much as younger patient from surgery and physical therapy, but when compare surgical and physical therapy in this age group, they're still going to benefit more from the surgery. They're going to have faster rate of improvement in this group from the surgery. This slide listed the strengths and limitation. I think the main strength of STORI is we have really good follow-up rate. At five year, we still have over 60% of the patient stay in our cohort, while for other research we see some like 30% at five year or some only have 5% of patient in the cohort. Another benefit is we use good statistic methods. Then limitation, of course, is a cohort study, lack of randomization. We still have unmeasured confounding and we do not have the MRI information for 17 patient because we think if we exclude them, we would cause some spectrum bias because those patients are more likely to go through the physical therapy treatment. Those are the conclusion I won't repeat here, but just advocate we need more randomized trial to test diverse population, to test those effect predictors so that we can better select the patient for a better decision-making process. That is the end of my presentation. Also thank you for the collaborators listed here. By the way, I'm also applying for PMR residency this year. If you know any opportunities, feel free to talk to me. Thank you. Thank you. Any comments or questions from the room? or which tendons were torn? Yeah, great question. So we did stratified analysis in several layers. First is that we tried to, at the main analysis step, we tried to differentiate the traumatic and non-traumatic. What we see is that there is no much difference over the five years between those two. What I'm saying is that the difference, the benefit from surgery, is still like around 10 points over the non-surgical treatment, no matter it's traumatic rotator cuff tear or a traumatic or degenerative. So we did not report them separately from here. We also tried to add it as an effect modifier in the model. Probably it's because of the simple side or whatever reason we don't know is not significant. So we did not include it here. Okay, thank you. In the interest of time, I apologize. We have to kind of boogie. I'm just, one comment that I think a follow-up cost analysis study could be very interesting in looking at the longitudinal surgical versus non-surgical treatment options, especially with the burgeoning of MSK care and PMNR. Yeah. Anyways, thank you. Yeah, the PROM is the front step, down upstream of the CEA analysis. Excellent. We are doing the CEA as well. Excellent. Good. More to follow. Thank you. Okay. So we're going to welcome William Niehaus from University of Colorado. Hello everyone, I'm Dr. Stacey and I'm Dr. Tracy, and we are the twin PM&R sports medicine physicians. I'm currently a PM&R sports medicine fellow at the University of New Mexico in Albuquerque, and I'm an attending physician at Columbia and Cornell in New York, and I do PM&R sports. So we are here to present on behalf of our co-authors on quantifying the dissemination of research in the PM&R journal via alternative metrics. And again, thank you to AAPM&R for choosing us as well. So no financial disclosures. So in terms of our study, social media has actually been a crucial instrument for the communication and dissemination of information in the digital age. So the official scientific journal of AAPM&R is PM&R, and in 2017, there was actually a new social media strategy that was implemented to help expand the journal's online visibility and increase engagement with all of its leadership or readership. So leveraging social media platforms, including Twitter, now known as X, to help disseminate groundbreaking research and to increase attention on topics in rehabilitation medicine has really helped in the potential to bolster our journal's standing within PM&R and within the other larger medical community. So in terms of the initiatives incorporated into the strategy, we actually aim to encourage further diversity among physicians and among physiatrists and to help promote the public awareness of different groundbreaking research, peer-reviewed scientific research, and also in the field of equity and in healthcare to access, or access to healthcare. So in terms of implementation science, implementation science is actually defined as the distribution of evidence-based research and medicine into policy and into the public sphere, which has helped and made a profound impact on various fields of medicine. So one of the main things that we used to use in terms of looking at the impact for these peer-reviewed articles would have been the citation count. So that still remains the gold standard. It's one of the, it is the gold standard of bibliometrics. However, with the impact and the rise of social media, there is now, there's now an increase in being able to disseminate our research. And so one of the alternative metrics is also known as the AAS, or the Alternative Metric Attention Score. So this is exactly what we're looking at. And the AAS is more of the weighted average of the number of online mentions on various media sites, whether that's on the news, on social media via Instagram, Twitter, or X, or Facebook, or any of the actual news coverage. So the AAS, we feel, can also help to provide a complementary assessment of the research impact that surpasses just the regular gold standard of citation count. So our objective was to provide a descriptive analysis of the social media impact of articles published in the PM&R Journal via AAS, or the Altmetric Attention Score, from 2009-2022. So right here we have some of our results. For all the articles published in the PM&R Journal, they were extracted from PubMed database using various terms, such as the Journal of Injury, Function, and Rehabilitation. That's the title of our journal here at AAPM&R. Our exclusion criteria was results with no authors listed, any posters. Any articles that were published in 2023 were also removed from the final cohort because of its recency, and then if there were any discrepancies in the DOI or duplicates. So a total of 3,300 items were published in the journal from 2009-2023 that were extracted from our database. And then after we did exclusions, 2,690 articles were used in our study. For these ones, we looked at the articles and that they averaged their AAS with 6.0 as the mean and the standard deviation of 34.4. Also of note is that our range was from 0 to 778.3. So if you see on our articles on our tables, we looked at the different breakdown from years. You can see at 2017 is whenever AAPM&R implemented our social media strategy, and from there we noticed a distinct increase. This is another table of about 20 articles of the top 20 articles that were included in the study. And you can see that a lot of the things, especially if it's more recently published, for example in 2022, their citation indexes or their citation counts was on the lower side, and that may be due to the recency of it being published. But you can see a lot that their AAS score is quite elevated. So for our discussion, we did notice a rise in the AAS score since the onset of the new social media strategy that was implemented through AAPM&R. And for the AAS, it definitely has a greater potential to serve as an important complementary metric outside of just the conventional citation measurements. And as you saw in a lot of the data, there's a big discrepancy in terms of the regular citation count versus the AAS. The advantages of the AAS are that it includes other news media, social media, in terms of being able to find out what is the true impact of these peer-reviewed articles, whereas the citation count, it's limited. It does not include those other factors. So it helps in terms of being able to see the impact, and then also to see the insights beyond academia. So in terms of different news coverage and social media, we all know that the audience is going to be different, versus in the citation count, it's usually more geared towards the medical field. And some of the disadvantages of the AAS is, again, the difference in interest between those in academia versus the regular people, lay audience. So given how quickly viral information can be propagated online, it can be difficult to control the spread of misinformation before corrections can be made. So with our PM&R Journal, we hope to continue to evaluate different ways to help amplify social media footprint, and in terms of circulating reputable research and promoting interest in the field. Thank you so very much. Thank you. Again, an excellent reflection on advocacy at work. Clearly your fields are MSK, and there's a really interesting output in terms of the work that you've done and what we're doing at the academy to advocate for all of us. Do you think we would have the same type of data from other subspecializations within PM&R, and would the efforts that we would need to take as an academy be different? So that's a very interesting question. So one thing that Dr. Stacey and I do outside of AAPM&R is that we are also involved with AMSSM, or the American Medical Society for Sports Medicine. That one is a larger organization because it includes sports medicine physicians from other specialties. And so one of our roles there with Stacey being the liaison for social media is that every single time that there is any kind of publication or any kind of event that's going on in the community, when any of our members are doing advocacy work or even just engaging with patients, et cetera, we really like to highlight them. And so I think in terms of AAPM&R, one of the great things that we have is the ability, like you were saying, to be ambassadors for our own specialty, for our patients, and for ourselves to really help educate the general public about who we are as PM&R physicians. And I think one of the great ways is through social media. Plug for us. We do fun dancing videos and to help advocate for patients with disabilities on our joint Instagram account. And again, that's our way of being able to help show the general public who we are as PM&R physicians, what is it that we do, what's our research and our clinical practice, and also the things that we do within our community. And I think also being able to attend these conferences, really network, advertise about what we're doing here at these conferences, the different speaking engagements that we're discussing, the topics, advocacy is really important. And so by us being able to do that, and then on top of that, being able to advocate for different parts, not just sports medicine, but also brain injury medicine, amputees and limb loss, pediatrics, and EMGs. And being able to do that will help increase awareness of everyone else for PM&R. I couldn't agree more. Thank you for making that point. And I think it's for all of us who are in here, whether you're a generalist or a subspecialist, you're a physiatrist first. So please help us spread the word that our speakers here are physical medicine rehab subspecialists in sports. So there's a difference in sports medicine by a primary care or an orthopedist or a physiatrist. So please do your part in helping to get that word out. Any comments or questions from the audience? Sensing none. Thank you. Thank you so much. Thank you. Okay. We're now going to welcome Austin Wong from Baylor College of Medicine. Dr. Wong. Oh, okay. God. This is so confusing. I apologize. We're going to do some remediation in our efforts to present here for the next sessions. So then that should leave us with just one left. Do I have a Yonathan Asefa? Yes. Welcome. Yonathan is from the Rehabilitation Medicine Department at the NIH. Okay, so my presentation is going to be a bit different than all the other ones today, but I hope you guys still enjoy it. So hi, everyone. My name is Yonathan Asifah, and I want to thank you all for giving me the chance to speak today. I want to thank all the authors and collaborators that helped me out with this project. They're not all listed, but to all you guys, thank you so much. So I'm currently working as a research fellow in the Rehabilitation Medicine Department at NIH, and my research focuses on using ultrasound to image muscles and nerves and track the changes we see in various neuromuscular disorders. And so, actually, what I'm going to be talking about today is Shearwave Elastography and Ultrasound Modality and its potential as a biomarker to track changes in Spinal Bulbar and Muscular Atrophy, or SBMA for short. So SBMA is an inherited X-linked recessive disorder, so only men will express the phenotype for this disorder, and it's caused by a trinucleotide repeat in the androgen receptor gene. Like the name states, it's atrophy of the bulbar muscles. Think like your jaw, your muscle, your jaw muscles, your tongue muscles, caused by brainstem neurodegeneration, as well as atrophy of your arm and leg muscles due to spinal cord neurodegeneration. And so there are multiple signs and symptoms of SBMA, but we focused on muscle weakness for this study because that's often one of the first symptoms that patients experience with this disorder. And so what's really sad about SBMA is there are currently no approved treatments for this disorder. There are ongoing investigational studies, but as of right now, there are currently no treatments. And the disease progresses relatively slowly, so we really need sensitive biomarkers to tell us what muscles and nerves are most affected, how severe is the patient's progression at the time of diagnosis, and ultimately, if we have investigational therapies going on, how effective are these treatments? And so that's where we hope to use this technology, Shearwave Elastography. And so the way Shearwave Elastography works is it'll send shear waves from the ultrasound probe and they move along the muscle tissue, and we can calculate how fast these waves move along the tissue, and that will tell us how stiff the tissue being imaged is. And so the machine will calculate how fast the shear wave is moving in meters per second, and it'll also provide us with a shear modulus, which is a measurement of a material's stiffness. And so to keep it really simple, higher velocity and higher modulus means more stiffness. So keep that in mind as we go. And so I want to also add that this technology is already approved by the FDA in imaging the breast and liver tissue with still investigation on the musculoskeletal, and so we're hoping to see how well we can use this technology to identify disease severity of people with SPMA. So when conducting our study, we did a longitudinal study with an initial visit and a one-year follow-up. We had a cohort of 11 people who were genetically confirmed with SPMA, and we underwent a standardized data protocol when we captured all of our ultrasound imaging. And if you have any questions about the details of that, please ask me in the Q&A or right after this session. I think I'm the last one today. So I want to add that we looked at five muscles, which you can see in the image on the right. And within each muscle, we looked at six regions of interest. So if you look at this image on the left, you'll see three circles up top, which is the superficial part of the muscle, and you'll see three circles in the bottom, which are the three deep regions of the muscle, and we looked at the shear wave velocity and that shear modulus at each of these regions of interest. And so with those objective values that we got, we correlated them to clinical metrics. One of them was the adult myopathy assessment tool, which is a tool used to assess a patient's functional status and their muscular endurance, and then we also looked at creating kinase levels in their blood, as creating elevated levels of creating kinase is often telling us there's some cause of abnormal muscular degeneration occurring. And lastly, within our cohort, we grouped them based on function. So we had an impaired function group, people with scores of less than 35 on that AMOD assessment, and then we had a high function group with people who scored between 35 and 45 on this AMOD assessment. So in our results, on this slide, this is the entire cohort, people with high and low function, and we found that of the five muscles we looked at, we saw that the masseter showed increased stiffness that correlated to a decrease in function. So for individuals that experienced the largest drops in function over one year, we saw the biggest increases in their masseter muscle, but other muscles didn't show this correlation. And when we looked at creating kinase levels over one year, we found that increased stiffness in the tibialis anterior muscle was associated with elevated creating kinase levels. And so, though we're in the preliminary stages of understanding cerebral astrography, we're seeing trends that selective muscle stiffness is linked to increased functional impairment and increased muscle deterioration. And so, when we separate for that high function and impaired function, we see that we're actually seeing an inverse of effects. So people who were showing impaired function, they were showing an increase in their stiffness over one year, but people who were relatively high functioning were showing a slight decrease. And the difference between those groups didn't quite reach significance, but it was trending towards there with a p-value of 0.052. And so, that is my results for you guys. So what can we conclude from this study? We do think that Shuave-Lestography does have potential as a biomarker for SPMA and other neuromuscular disorders. When imaging is done for people with neuromuscular disorders, we typically just image their arms and their legs with like an MRI, but we often neglect those bulbar muscles. And when we compare ultrasound and Shuave-Lestography to other methods like MRI, it's a lot less expensive, a lot less invasive. And so, we really do think that ultrasound does hold some value as a diagnostic imaging tool for both SPMA and other more common neuromuscular disorders. Our study does not come without limitations, though. It was only done over a duration of one year, and also the musculoskeletal, it's a very heterogeneous system. Each muscle is oriented differently and has different properties, and that might be influencing the results as well. And Shuave-Lestography in itself is a very sensitive technology, so it really requires standardization of how you conduct it with each patient over time. And also, things like variability of disease progression or operator dependency might have also influenced our results. So going forward, of course, we'd like larger sample sizes to help increase our power. It's a rare neuromuscular disorder, so we're doing our best. And ideally, a longer period of time tracking these changes. We'd also like to see how Shuave-Elastography correlates with echogenicity, and that means how bright a tissue is when we look at it via imaging. And also how thick these muscles are, how much of they atrophied in thickness. And lastly, we'd like to see how these Shuave-Elastography values correlate to functional tests of the bulbar muscles in particular. So that's all I have for you guys. Any questions? I'm personally very excited to see this level of research, rehab-specific research being done at NIH. So kudos to you and your team and I hope you can build on what you've created. Any comments or questions from the audience? Well, thank you. Is there anybody in this room who was supposed to be a part of any of these sessions who was not called on? Okay. Well, thank you again for all of you who submitted to the AAPMNR, those of you who came and presented. We really value your educational input and you're the burgeoning success of our field. So please continue doing what you're doing. Thank you to our reviewers, if any of you are in the room for the hard work they do behind the scenes and getting to this point. And I just want to welcome those who were presenting or affiliated. We're going to take a group picture at the end of this if you have time, just to highlight some of the things that we've done. So thank you. Thank you.

Physical Medicine and Rehabilitation

Medicare reimbursement trends

rehabilitation service usage

trauma units

post-liver transplant

rotator cuff tear treatments

social media impact

Shearwave Elastography

Spinal Bulbar Muscular Atrophy

interdisciplinary approach

patient care outcomes