Hello, it is a great pleasure to welcome you all to this session at the annual meeting of the Academy of PM&R. Unfortunately, we had to go virtual, but I think you are in for a great, great educational experience. I have with me, I think three incredibly bright and innovative individuals who are going to be talking to us today really about what the future of rehabilitation medicine is, and I mean that really in a way that should convey to you the importance of their long-term vision of where we're going in rehabilitation. I'm going to introduce to you these three wonderful speakers. They will each be making a presentation, and then we will have a time to have a short exchange between the four of us so that you get a better sense of where these discussions are going. First of all, I'm going to introduce Dr. Dave Binder. Dave is an assistant professor of rehabilitation medicine at the Harvard Medical School. He is a physiatrist with a subspecialty and board certification in pain management. He is the medical director at the Spaulding-Cambridge Outpatient Center and the president of the medical staff for Spaulding Rehabilitation Hospital. He also serves as the Spaulding Rehabilitation Network medical director for outpatient virtual care and director of innovation at Spaulding, and so he'll bring to us really a perspective on how to foster and implement innovation in the field of PM&R. He will be followed by a colleague and friend, Dr. Ning Chao, who is the co-director of the Stroke Rehabilitation Center at Moss Rehab. She's a clinical associate professor in the Department of Rehabilitation at Thomas Jefferson Hospital, and she's going to really talk about what she has been doing for the past many years, which is translating advanced technology into stroke rehabilitation clinical practice. She has led a number of interesting projects and has done work from robotics technology to 3D printing and how it's applied in rehabilitation. And he has been a speaker nationally and internationally in many of these topics. Finally, we're going to hear from really the motivator of this session, Dr. Jeffrey Myers, who is a well-known board-certified physiatrist. He's an acupuncturist, an educator, and has an extensive background in holistic evolutionary biological approaches to rehabilitation medicine. He's really interested in the arts, the spiritual part of science, and has really done a great job at translating what he does day-to-day in interacting with patients into this more holistic approach to medicine. And he's going to be talking to us about the science of adaptation. And I forgot to mention that Dr. Chow is going to be talking to us really about the application of implementing robotics in stroke rehabilitation, in the acute phase of stroke rehabilitation. Now I just realized after telling you all of this that I forgot to introduce myself. I'm Alberto Eskenazi, and I'm the chief medical officer at Moss Rehab. And it is, again, my great privilege to have you all here today. So we'll start with Dr. Binder. Dave, the forum is yours. Great. Thank you so much, Dr. Eskenazi. I really appreciate the opportunity here. And thank you all for joining us today. My name is David Binder, and I'm going to be talking today about fostering and implementing innovation within our institution. So what I wanted to start off in what is going to be kind of a recurring theme that I'll talk about is just the innovation ecosystem that we all have. And by ecosystem, what I'm referring to can refer to many things, people around you, institutions, organizations, companies. But one thing that's important to realize is that we have an innovation ecosystem within our own hospital or clinical practice. And then there's kind of an external innovation ecosystem with resources and knowledge that is very complementary to the healthcare knowledge that we have. So oftentimes, I feel that to be successful in innovation, you need to recognize the resources that you have around you and try to utilize those to the best of your ability. And I'm going to talk a little bit about some of the things that we've done at Spalding Rehab and the innovation program that we developed as a little bit of an example and a template for some of the things that can be done. And what led us to develop this innovation program here is this. We realized that if we have an idea within our institution or our employees or clinicians or patients have an idea or identified a way to improve on processes, where do they go? How do you improve that? Who do you call? And we wanted to kind of streamline the process to facilitate innovation. And so that's why we created the Spalding Innovation Program. And so I think first and foremost, the important thing to try to achieve is and recognize is that you can't really go about innovation by yourself. It's just not going to work. You need a team. You need people around you. You need subject matter expertise, and you need a collaboration. People to bounce ideas off of, people to talk things through. And so one of the first things that we did is we tried to identify people within our organization that just had an intrinsic interest in innovation and try to utilize their expertise to complement kind of the larger innovation team. The other idea that we had is recognizing that we're a very large organization. So how do we reach out to the people within our organization? How do we try to funnel ideas towards some sort of central area so that we can identify, you know, ideas that, you know, we want to move forward or problems that maybe we didn't even realize were there? So we set up an email resource and an online resource where people could actually just click on this button and they would get a little questionnaire, an idea portal. You could just put in some basic information and just tell us a little bit about what you're seeing on your end. What problems are you seeing? What ideas do you have? And then we would reach out to them just to see if we could help in some ways. And sometimes, you know, it was an idea that, you know, we could actually connect people together. Sometimes it was an idea that, you know, we weren't able to help. But at least, you know, kind of what people are thinking and potentially problems within the organization that maybe you didn't even realize were actual problems. The other thing that we realized that we wanted to do is really set up an online presence. And so, you know, everything's online these days, right? So we wanted to just set up a dedicated kind of web page on our website for not only us, resources that our employees, clinicians could access, but also kind of a patient-facing and consumer-facing website that people that are kind of going around the general website for Spaulding would be able to not only know our different sites and facilities and different doctors, but also the research that we're doing and some of the innovation projects that we're doing. And so this is just some screenshots of our website that we created. Internally, we wanted to create a resource and support for innovations, ideas that we had within the organization. So we created a Spaulding Idea Incubator, and this is just a way to funnel ideas in, talk things through with the right people, and see if we might be able to support people in these endeavors, whether it's with some sort of protected time or other resources that might help them. I think it's important to try to create a culture of innovation within the organization. You know, you think about the organizations external to health care that are known for innovation, whether it's Tesla or Apple or some of these other organizations, Google, right? And what you realize is that they try to really create a culture of innovation within the organization. You walk in the lobby and it's just a really cool, innovative, unusual lobby, right? So right off the bat in their organization, they are setting the tone as soon as you walk into the building. And so that's what we wanted to do at Spaulding as well. And one of the things that we wanted to try to convey and educate our clinicians, our residents, and all the employees within the Spaulding network is maybe not only what we're trying to do and what we're doing, but how about what other people are doing outside of our four walls? And so we brought in speakers for our ground rounds, our Spaulding Innovation Ground Rounds. We brought in people like CEOs of different companies, health care related companies. We brought in managers, executive directors of innovation programs throughout the country. This is an example. She's the Andrea Pulido was at the time an innovation director at the B.A. health care system. And then this is another example of health care kind of support system that we had within the state of Massachusetts. And so we brought some people in to to talk a little bit about that. For those that are within kind of larger health care systems here at Spaulding, we're part of the National Brigham Health Care System. And so we realized that there was also opportunities to support and develop innovation within our larger organization. So this is an example of a program that we had at Mass General Brigham, where it was a program intended to identify and support translation of research. And so, you know, I would just make the point that, you know, oftentimes you know, if you start looking around, if you start asking questions and you'll realize that there are there are programs out there that could help and support innovation wherever, wherever you are. And so those are some of the things that we did internally within Spaulding Network and also the Mass General Brigham Network. But we also wanted to try to create a bridge to some of the external organizations and institutions that we have here in the greater Boston area. And I think that this is a great slide that illustrates that really successful innovation is going to take a lot of different subject matter expertise and resources. And and so it's not just about the clinician and the physiatrist, but entrepreneurs and venture capital universities, biotech, pharmaceuticals companies, all of these organizations can help us achieve whatever our goals are. And so that leads me to the topic of a health care hackathon. So briefly, what a hackathon is, is the idea of bringing in people together of different skills and mindsets to try to solve through problems. This originally was created within the tech world. People, coders would get together to try to create and code for a problem, create a solution that they had. The idea spread to the health care industry. And the idea here is, you know, if you think about it, to try to set up a meeting is always hard. Right. So if you think about trying to set up a meeting, let's say with a clinician, a physical therapist, an entrepreneur, a lawyer, an architect, if you want to get all these people in the same same room, it would be pretty hard. Right. And so a health care hackathon essentially is is is a way to get all these people in the same room. It's it's an event where you invite all these people on an evening or a weekend. Everybody comes and then through kind of a series of steps, you work through problems and you create solutions. But it's a very efficient way to create kind of innovation. We created the first we have medicine hackathon back in 2016. We invited guest speakers. We had a two day hackathon where you start with a keynote address. You talk to people a little bit about the event. You have a pitching session. And what that is, is anybody that goes to the event, the event gets 30 seconds on stage to pitch an idea. And and that's it. And then afterwards, what you do is you kind of just group together, you talk to people about what you heard on stage. You can say you might say something like, hey, you know, you said that one thing about a problem that you have at work. I have the same problem. Can I work on your team? And the hope is that you create these these teams organically and that you kind of work through the problem together over the span of a day or two. You make it fun. Right. So there is a competition at the end of the day. What you're able to do is pitch in front of judges that are able to ask questions, give you guidance. And then ultimately there's a there's a prize at the end of the event. So it's a really fun way to get people together and and try to solve problems not only within your organization, but also in health care in general. We did a couple of these hackathons and then we did an online version of a hackathon where we called it the Innovation Challenge. We got some sponsorship and it was really a great event where we brought in some early stage startups to try to win this this competition. We had judges, we had audience participation. So that was a really fun event. As you do some of these things, you you have opportunities to talk to people about it. People will ask you about it. And oftentimes there's opportunities to get a little bit of press about what you're doing, which just kind of helps everything. It helps the organization. It helps you. And it helps other people know what is going on within the innovation program. So as I conclude here, one of the things that I would just like to point out, aside from understanding the innovation ecosystem around you, is to step back a little bit and think about why we're doing some of these innovative type of of things. Right. And I think it's important to take stock of our stakeholders, which ultimately, number one, are going to be our patients. But it's also going to be within the organization, within the larger organization, Mass General Brigham, the employees, but also government agencies, insurance, the state organizations. There's a lot of stakeholders in what we're doing in the health care, and it's important to recognize those. Also, there's this idea of a SWOT kind of diagram, which is to, again, step back and just critically think about, all right, within the organizations, within yourself, within your team, what are some of the strengths? What are some of the weaknesses? What are some of the opportunities, the low hanging fruit out there? And what are potentially some of the threats, not in a bad way, but some of the threats to not being able to succeed in what you're trying to do? What could some issues be? Costs, funding, things like that. And I'll finally leave with, again, just to reiterate the innovation ecosystem, probably the most important thing here, because, again, you can't do these things by yourself. You need a good team. You need to recognize the resources and the people around you that will help you kind of move forward. So with that, I just want to thank you all for attending our program and thank you for the opportunity. And I want to hand it over now to Dr. Chow, who is going to talk to us about implementation of robotic assisted robotic assistance in gait training. Thank you very much. All right. Thanks for Dr. Binder's wonderful talk regarding the innovation ecosystem, which is very impressive. So now I'm going to share the real world experience, how we translate one of the innovation ideas to the clinical practice at Mass Rehab. I don't have any financial disclosure for this talk. And so for audience who are not familiar with the robotic assisted devices, there's a general there's two kind of devices in the clinical application. One is called end effector type, which is designed based on a double crank and a rocker gear system and a work by applying mechanical forces to the distal segments of lips. Another kind is designed as robotic gait oscillosis combined with the harness supported body with support system used together with a treadmill. Nowadays, you know, there's another isoskeleton type can be utilized over the ground for gait training. So in general, the principle of the robotic assisted gait training, there are many advantage compared to the conventional gait training. So using the body with support system, we are able to the clinicians are able to providing higher intensity repetitive training. And nowadays, you know, the task specific high intensity training is a principle of resulting neuroplasticity changes and helping the patient recover the walking capability better. So another very important role for robotic devices, as we can see over here, as figure A and B, compared to C, with a robotic-assisted device, and we are using less physical support from the physical therapist, and we can provide longer duration and higher-intensive therapy. So there's more and more research demonstrating the mechanical-assisted walking with a body weight support system can help the patient recover the walking function post-stroke, and this is six studies comprising 549 participants in the systematic review, and they have found mechanically-assisted walking with a body weight support is more effective than over-ground walking in terms of independence and also the walking quality. So another question is, you know, the therapy would ask whether the treadmill training with the body weight support system really can restore the physiology type of walking capacity, and if we can look at this study in the randomized control trial, 126 patients who are unable to walk within four weeks and received experimental group using the treadmill training with the body weight support system versus conventional training, what they found, actually, the treadmill training with the body weight support system helping the non-ambulatory stroke patients improve walking capacity in terms of the quality parameters. In addition, for the training device, as we can see, the higher intensity of the stepping activities in the training or throughout the training duration really can be translated to the improvement in the community ambulation, so there's a positive association between the dosage and response. So this is another study, included 15 randomized control trials. What they have found based on the meta-analysis, a significant, although small, effect on walking dependence and endurance if we're using the robotic-assisted gait training devices compared to on the left side if we're using the manual assistance, and also based on their observation, the robot-assisted training was most effective in those patients with a poor prognosis. So the rationale is, you know, the more effective patients generally do not engage in intensive rehabilitation under conventional condition. The robot-assisted training gave them the opportunity to engage the higher intensive training. So based on the research study, we have explored the feasibility of the locomotor training in our own acute inpatient rehab facility at MOS. We have enrolled 30 patients, and the majority of the patients had ischemic stroke with the left side witness, and our findings also provide a proof concept demonstration and additional lower limb exercise using local mat in combination with a mandate multidisciplinary therapy, three hours one-to-one therapy in acute stroke population is feasible. Although higher intensity, the training more beneficial to the severe stroke patient population, in reality, we have observed actually the more severe of the stroke patients and less active in the physical therapy sessions, which is really observed worldwide. This is a study conducted in UK based on the observation of 107 stroke patients. As we can see, there's a negative association between increasing stroke severity and percentage of the time undertaking active exercise in PT sessions. So using step watch, the ankle accelerometers, we also have found in our acute inpatient rehab facility, the non-ambulatory stroke patients are very inactive. So we can see that the as we can see here, throughout the day, the patient only engaged one or two hours at most of the physical therapy as a top graph demonstrated. The rest of the day, the patient basically is no walking practice at all. And the graph at the bottom, as we can see, if we record the stepping activities from admission until discharge, the whole duration of the length of stay, actually the patient only engaged 14 steps at the most hundred steps by discharge. However, on day 28, we use the local MAT robotic assisted devices. We have the higher, much higher magnitude of the training in terms of the stacking counts. So this is our real world experience. So based on the observation and literature review, we are one of the leading facilities have the largest collection of the robotic devices. So that is the reason we really want to implement all the technology into the real world practice. The initiative was started in 2019. Although before we had all the education and training for the treatment team, but we never had real world outcomes collected from our real world practice. So in 2019, March, we started this innovation program. What we have done is we enjoyed the patients with a stroke diagnosis. As soon as admitted to the inpatient, acute inpatient, we have program and mask. The strategy we use, we encourage the treatment team integrate robotic training into the regulated clinical physical therapy session. So the treatment team has to prioritize locomotor training in physical therapy sessions. Although not mandate, they are highly encouraged to use treadmill versus over the ground with and without body weight support system to provide the higher intensity of the training. And for patient who needs assistance for ambulation, the robotic assisted gait training devices were highly encouraged. So the locomotor training devices during the implementation period available at our facility are locomat, geo system, andago, alter G, and safe gate at that time. With the ongoing acquisition efforts, now we have larger collection of the devices. So what we have done in this innovation program, as soon as the patient admitted to acute inpatient rehab unit, based on the assessment of their walking capability from the physical therapist on admission, we defined different level of the functional level. The low level defined as patient does not walk more than 15 feet or they require assist of more than two person to walk or only using parallel bars and rails. Then what we do, we apply the ankle accelerometers as we can see from the figures and to the practical lag from the morning 730 to 5 p.m. on weekdays. And we downloaded the step counts by the end of the inpatient rehab stay on discharge. And we documented in the chart the identified to match the information to the EMR. Another tool we have used is the pulse oximeter to monitor the heart rate and oxygen saturation to reassure the patient is safe and they are making the voluntary effort. The target maximum heart rate is 60 to 85 percent of the range. And also we are using the scale to monitor the intensity of the training. As we can see, by the end of the implementation, in the October of 2019, we reviewed 105 hospital electronic medical charts to determine whether it's feasible to accommodate the robotic-assisted gait training device in the PT session. And there were 37 files were considered as low-level mission. We excluded patients who did not complete the inpatient rehabilitation program due to medical complications and those whose steps were unable to be recorded and tracked. And there were 33 patients for analysis. Among the 33 patients, 10 patients were found to utilize the locomotor devices. Consistently, we defined as at least three times a week and greater than two-thirds of the length of stay during the acute inpatient rehab. And these individuals were identified as the locomotor group for analysis. Based on our analysis, you know, this is very feasible. These 10 patients, we did not observe any adverse events related to the devices. And in order to see any preliminary efficacy, we also did further analysis, look at the clinical characteristic of all these patients. As we can see over here, there's no statistical significance difference between two groups in terms of the demographic characteristic, the type of stroke, as well as admission fin score, which is commonly used quality indicator under the Medicare regulation. As we can see here, the locomotor group, which represented by the orange color, showed greater motor gain at discharge compared to the conventional group. And also the conventional care group performed on average 500-something steps per day compared to 1870 steps per day for the locomotor program, which is statistically significant difference. As we can see over here, there's a positive correlation between the number of steps performed in daily therapy versus the fin motor gain. However, we do have relatively higher percentage of the patients were not able to receive robotic-assisted gait training program, although the driver for the implementation are the treatment team. So based on the surveys and interviews after the implementation, we identified several barriers for the implementation of the innovation ideas. The patient individual needs need to be really geared based on the treatment team's clinical decision because we do have a large collection of the devices. Some of the clinicians really have a hard time to match devices to meet the individual's need. That's the knowledge gap we have to work on by clinical practice in the daily physical therapy session. Another demanding question the physical therapy won't address is how we prioritize the intensity of the practice over traditional approaches under Medicare regulation if the devices need a longer time of setup to be utilized in the clinical practice or there are other clinical demand tasks need to be documented and implemented in the regulated PT session. As other studies demonstrated as well, the medical complexity of the acute inpatient rehab at MOS, we do have similar barriers, how hard we can push those patients who have fatigue and pain, the blood pressure issues, severe spasticity and also cardiopulmonary comorbidities. And patients who have aphasia, cognitive impairment, behavioral issues, we do have a challenge to implement the robotic assistive training devices consistently. Systematically, we do have the lack of support from the payers regarding the education, the devices acquisition. We don't have any reimbursement from the payers. Based on the implementation experience, moving forward, we identified several directions we want to implement at the next phase. The intervention protocol needs to be optimized to tailor to the individual patient's needs. And we want to use the step watch or accelerometer or any other kinds of sensors to provide the real-time quantification of the intensity of the intervention, give the clinicians and patients feedback, and also we want to emphasize the robust data collection. Based on the technology we implement, then we can further optimize the algorithm. And the successful implementation of innovation idea rely on perceived benefits and phased implementation. And in the end, we really want to apply our real-world experience to reduce the gaps between robotic design, development, research trials, and clinical practice. So in the end, I have to thank the whole stroke rehabilitation team working hard with me, and also the management team support, you know, in terms of the resource and also the visionary from Dr. Espenazi make all this innovation ideas can be translated into the real practice. So now I'm gonna give the time to Dr. Mayer to really discuss as a physiatrist how we are gonna adapt the science. It's a science of adaptation. Thank you. Thank you so much, Dr. Chow. Hang on just one second. So my contribution to the future of rehabilitation is physiatry, the science of adaptation. And I have no financial disclosures to make. And I'm going to give the takeaways first just because we don't have much time to go through a lot today. But the key point to remember throughout the whole talk is that PM&R is the science of adaptation. And I'd like you to keep this in mind almost like a mantra through the whole talk, and maybe it'll reveal some new insights to you and change the whole approach to your practice. So takeaway two is that the goal of PM&R is maximizing health or peak performance, or in one of the terms I'm gonna talk a little bit about later, actualization of the whole person in their environment. And that there are basic sciences of whole person functioning that are the foundation and actually the vocabulary of PM&R. And they haven't been integrated into the specialty, but they're unique and they'll be necessary to drive the healthcare of the future. And these sciences in relationship to technology, they become more robust with the explosion of our ability to quantify all types of data. With the advance of technology that allows mass data gathering and analysis, we're able to quantify function that was considered qualitative in meaningful ways that weren't available in the past. And this can actually represent a revolution or a paradigm shift for our specialty for assessing and understanding function. And it provides a unique niche for PM&R that sets us apart from all other specialties and can drive us into the future. I've been interested in holistic theory in neurology since the 1990s. I actually went into PM&R because it seemed like a specialty best suited for the study and understanding of the health of the whole person in relation to their environment. This is not the wholism of Whole Foods or complementary medicine or alternative medicine, but the holistic approach in neurology that studies the special and distinct natural laws and biology that govern the patient or organism as a whole. These laws may not be present when we break down the patient into systems or organs or tissues or cells. This is not to criticize our current model, but to support including a whole new paradigm of study and understanding of our patients that reflects our role as physiatrists, as physicians who maximize function. The origins of holistic theory go back to the 1940s in neurology with Kurt Goldstein. There's his book After Effects of Brain Injury and War, and also Andres Angel, who was a psychiatrist, also interested in this perspective. There were a couple articles that were written by people with a PM&R background, such as Gary Goldberg wrote this article in the 1990s. In the way that classical physics and quantum physics coexist, and they bolster each other and fill in the gaps for each other, the holistic model can fill in the blanks about many areas of understanding of our function. The holistic model looks at the same patient in a different way from a different level of biological organization. Why is this more relevant now? Of course, because of digitalization and big data. In the past, even though holistic theories had their advocates, we couldn't research them as well, as there was no good way to get objective data about so-called qualitative behaviors. But now we're able to quantify behaviors that were considered qualitative, and are becoming able to derive meaningful information from the data in a way that was never possible before. This is just the beginning. Because we can now analyze big data, of course, we're using gait labs in ways that can give us information about mechanical forces that affect efficiency and pathology, and some of the things that Dr. Chow was talking about. But we can also measure things like facial expressions in ways that give meaningful data about personality, or mental state, or emotion, from measuring autonomic tone and muscle patterns through EMG. And we can also measure autonomic and micro-expression parameters in ways that can predict within 90 percent whether a couple in therapy is likely to stay married or not. So what does the future hold for physiatry? Will we be able to use wearable devices such as a shoe insert or socks, and integrate them with imaging, and precisely predict the progression and timing of someone's arthritis years down the line by looking at gait patterns? Or look at the precise relationship of gait to the expression of personality? Or how far will we be able to use direct brain-controlled computer interfaces to control activity outside our bodies, and map the brains in diverse populations? Or map virtually every neuron in the brain to look for associations with diseases and the way we think, or better understand each person's unique neurodiverse expression? These are all things that are being researched and funded right now. So the future of PM&R from the BOLD project is admirable, but for it to be successful, it needs to incorporate what's unique and essential, and at the core of physiatry in relation to all the other medical specialties, with a foundation that integrates the whole specialty. We must ask, what's the central unifying principle that unites our diverse subspecialties? What's at the core of our mission? What's truly unique about the specialty that embraces and integrates all the diverse populations that we work with? So if the specialty of urology unites around the bladder, and the specialty of oncology focuses on all cancers, what's the heart of PM&R? Of course, it's adaptation. This is the organizing principle of the whole specialty, from peak performance of athletes, to burnout prevention, to spinal cord injury, brain injury, pain, amputations, and adapting and reintegrating them into the world. When adaptation is a central principle, it leads to the unlocking of an integrated, holistic natural science of PM&R that's been hidden since its founding, and it gives a clear path toward advancing the specialty in a future in a way that's unique, that no other specialty is set up for. So when we have organismic adaptation as a central principle, we look at the total functioning of the whole patient in their environment. Successful adaptation is successful functioning of the patient in their specific environment, and assessing and treating of any parts is in service to the functioning and adaptation of the whole person, and it's a diverse and inclusive approach. So if adaptation is the heart or organizing principle of PM&R, what's the soul? The soul is this holistic approach that involves truly treating the whole person based on a true integrated natural science of the whole person, and this approach has been supercharged by our ability to analyze big data. So before I talk a little more about the quantitative sciences that are at the foundation of this holistic approach, I want to start by giving a definition of health that comprehensively addresses all the types of patients we see as physiatrists, and it's a useful definition of health to be put forward in all of the rehab training programs. So in the 40s, you know, we had pretty much a primitive view that health is the absence of disease, and in 1948 the WHO came up with something a little more comprehensive that it's complete mental, physical, and social well-being, but what's the most useful definition of health for a physiatrist? The continuum model of health, which looks at the ability of a patient or organism to achieve balance or homeostasis and thrive in a particular environment. So this definition is dynamic, it's relative, it's diverse, it's inclusive, and it's fluid, and it depends on the patient, the time, the place, and the ecosystem, and it embraces the physical diversity and neurodiversity we see in all of our patients in PM&R. So it takes into account that the biology of what is asked of the organism for peak performance or health in this moment is quite different than the biology of what's asked to fully actualize the potential of this moment, and it's different than what's asked in this moment. Who is that guy? So with this definition, the question to ask at each patient visit is what can I do to balance the patient within their environment? And using that model of health as our goal in PM&R, we can now begin to look at basic sciences and methods of investigation that let us truly study whole person functioning. Our future as a specialty is based on many now quantifiable tools of measuring and understanding whole person function, and this is part of the true foundational vocabulary of PM&R that uniquely fits the holistic nature of our specialty. And these technologies and methods can turn so-called soft skills into measurable skills, and they should all become part of an ability-inclusive educational development agenda for the future of PM&R and shape our practice approach. So first, we'll talk briefly about evolutionary medicine, which looks at illness and health in the context of evolutionary imperatives. Adaptation, survival, what are the requirements to survive and thrive in specific ecosystems and shape our treatment based on that? And it gives us insights into designing ecosystems for surviving and thriving in different environments. The holistic approach, which I just talked about, that requires an understanding that there are different rules and laws of biology that apply at the whole person level, and we've got to get on the bandwagon and be interested and study this stuff. Complex systems theory that uses mathematical analysis and modeling of complex biological behaviors and different levels of function, including the cellular through the whole person and the whole person in relation to their environment. And it's used to find patterns and quantified meaning right now in like traffic or weather systems or stock market training and make some kind of sense out of that. And it uses approaches such as Ilya Prigogine's Nobel Prize winning work that looks at how orderly and stable systems can derive from disordered ones. And this offers an approach to looking at illness and health. Ethology and sociobiology, the study of animal and human behavior under natural conditions in the ecosystem. And these offer methods to compare function between different species and it studies the evolutionary basis of behavior due to pressures on the environment. So you can look at how a flatworm moves in relation to how a soldier has to jump in a spontaneous movement. Nonverbal communication and micro-expression, which I talked about, looks at the links between a whole person's movements, motility, behavior, and emotion. And this type of work is now being used in law enforcement to sort out potential terrorists at an airport based on body habitus, facial expression, and macro and micro movement, among other things. Human development across the lifespan, to compare the different competencies at different periods of development and in different ecosystems and how the competencies change as we're going, as we're healthier longer. So what's looked at as end of life for elderly, maybe in 20 years, if we're living to 120, we will be finding new functions for the older individuals, including me, I hope. And lastly, phenomenology is the philosophical heart of these disciplines. And that considers the moment to moment experience of each of us as bodies in the world. And what's the meaning or importance of the biology of each moment to health in that moment and across the lifespan. So exploring the experience of the way you're grinding your jaw right now, watching this presentation in the context of how might that contribute to the neck pain that you're going to have 20 years from now. All of the above sciences have been supercharged by the potential of big data and they're becoming exponentially even more robust every day. Our newfound ability to break down and measure almost any pattern or expression of human or plant or animal behavior into bits of information and look for quantifiable meanings is truly a paradigm shift. Is there a quantifiable meaning or clue to health to how a person moves that can be compared and contrasted at a macro level for meaning? What does Marilyn Monroe here, her expression tell us about the integration of emotion and autonomic tone and the muscular system? Or what does the way an amoeba moves tell us about the meanings of the constant micro movements going on every moment in our cells and tissues and the whole body? Or is there a quantifiable meaning or relationship of how a plant dances to light or a person stretches or yawns? These questions stretch the realm of physiatry and the science of adaptation and overall function and can now be studied objectively. And in terms of technology, if we create realer and realer alternative environments and universes that we or for example a neurodiverse person like a head injury person chooses to live in in which we have more function than in our so-called objective world, is it ethical to choose to live in that world, the virtual world? But truly which world is more real? Can rehab be can rehab be a mass customization where everyone can function at their peak potential in the environment they choose? It's truly a time of a potential paradigm shift in PM&R. But the elephant in the room is of course the moral and ethical questions that arise from these new technologies and sciences in order to make the decisions that as we all say add life to years and lead us to the place where all of our uniqueness and abilities can shine through. So these are just a few brief resources that are will give you just the general gist of things that I like and thanks so much for your time and I'll hand things over to Dr. Eskenazi. Thank you very much Jeffrey. That was a wonderful presentation and I want to extend my gratitude to David and Ning for really brilliant presentations and I'm going to ask both of them if they could come back on the screen. You do the same Dave please and maybe we have a short opportunity, we have a few minutes left in this meeting, to really review of what you've talked about and the impact of what you're saying and showing us and educating us as we move forward in the future of rehabilitation. I want to start with Dave, maybe he can comment briefly. I love the fact that you've created really a whole structure behind the concept of developing innovation and although this seems to be relevant particularly to technology, I think that you're talking about bigger than technology. Am I right when you discuss your structure of innovation? I think that's absolutely right and I think that that's a great point because oftentimes we think about innovation as a product, a technology, you know an app, but the reality of it is that some of the things that really can make a huge difference you might not even see. For example, making a certain hospital process a little bit more efficient, doing something in a little bit of a different way that saves somebody time, I mean that's a huge value to not only a person but the organization, a patient that gets care earlier in a more efficient way. So absolutely, I think that's a great point. Innovation comes in various forms and I think there's innovation everywhere. Great and maybe Ning, you could talk a little bit about the fact that you see innovation in technology and so you've really migrated your efforts to reduce, maybe reduce the after effects of a tragic or a significant event like a stroke, but at the same time you've seen it really as a way to develop a whole new approach to rehabilitation and you did briefly talk about the struggle that it is to fit the mold of the governmental regulations, three hours of therapy in one way, but at the same time add your innovative approach to gait rehabilitation. Could you talk just maybe in a word or two about that conflict and how it really impairs the development of innovation? Yeah, so in order to comply with the regulated physical therapy session, so when we talk about the robotic or higher intensive gait training is more beneficial for a severe stroke patient's recovery. However, because of the regulation, we are not able to extend the duration. We believe longer duration, higher intensity is going to be beneficial. However, without the robotic gait assisted training device, we're not able to achieve that because we're not able to adding more therapy session or beyond one or two hours physical therapy session. So that's the innovation come around to help us. Great. And this brings me to Jeffrey and really talk about this idea of a holistic approach in which you're really thinking about the individual, thinking about the environment, and then how you pull that together to advance not only the goals of physical medicine rehabilitation, but truly the goals of the patient. And I thought those examples that you showed us of the different environments and how we adapt to the different needs at each instant are of critical value. So maybe you could just close with that if you'd be kind enough. Sure, because yes, really we are looking at peak performance for all of our patients, right? We're looking to do what they call that word actualization is bring everyone to their fullness. And we're all diverse and unique in our own ways. And this is really, even though it's using technology, it's very patient focused, right? Because it's how do we really maximize everyone's potential and using technology to increase the humanness. And we have all of these things at our fingertips and all of these new sciences that we couldn't really quantify before. So I believe we're just at the beginning and that PM&R was waiting for this moment to be able to start quantifying function, rather than looking to how can we support other specialties, we can really be the leaders because we're looking at this new age that's coming into existence because of the usefulness of technology. Well, that's wonderful words to close this program. I want to thank the three of you. This program really is very meaningful, not only to me, but I think to all of the members of the Academy, I hope they appreciate and they reach out to each one of you, really as leaders in this idea of innovation in rehabilitation and developing the future of the field. So thank you to all of you. I know that it's hard without having feedback or virtual applause, but let me really give you a great thank you and a congratulations. You did an excellent job in getting this session done. And on behalf of the Academy, my very, very much gratitude to you. Thank you. Thank you. Thanks so much.

rehabilitation medicine

innovation

collaboration

robotic-assisted gait training

stroke rehabilitation

science of adaptation

holistic approach

technology

big data

patient care