Well, thank you all for joining. It is my honor to be here with this esteemed panel to discuss a topic that's really near and dear to us. We're all very passionate about it. And over the course of the last several years, we've run into each other at various conferences and been informed of what we're all doing at our different locations. But the common thread is this passion about the need for aerobic exercise and stroke rehab. So I'm Susan Linder. I'm a PT by training. And I have a research lab at the Cleveland Clinic. I primarily investigate the role of aerobic exercise in neuroplasticity. So I look and I will be discussing some of our outcomes related to that. Dr. Sandy Billinger is also a PT PhD. And she is a professor and vice chair of the Stroke Translational Research and assistant director of the Neuroimaging Corps at the University of Kansas Alzheimer's Disease Research Center. Dr. Billinger is a co-PI and co-director of an NIH funded T32 brain health training program also at the University of Kansas. And if any of you have followed the prescription for aerobic exercise and stroke recovery, Dr. Billinger is the primary author and led that writing group. And Dr. Talia Fleming is the medical director of the Stroke Recovery Program at JFK Johnson Rehab Institute in Hackensack Meridian Health in Edison, New Jersey. She and Dr. Cucurulo have developed a really innovative modified cardiac rehab program that they will present on. Dr. Fleming is also an associate professor at Hackensack Meridian School of Medicine and Rutgers Robert Wood Johnson Medical School. And last but certainly not least, Dr. Cucurulo is the chair and she's a clinical professor and residency program director of physical medicine and rehab at Rutgers Robert Wood Johnson Medical School, JFK Medical Center. She is also the medical director and vice president of JFK Johnson Rehab Institute and physician in chief of Rehabilitation Care Services. What is really cool is these ladies have been in front of CMS to really drive change in policy so we can advocate for our patients and validate that aerobic exercise is a skilled therapy and it is a skilled need in this population and it should be covered by Medicare and Medicaid and other payers. So without further ado, I'd like to invite Dr. Billinger to the floor. Well thank you all very much for being here today and also... I have a really loud voice. There we go. And for coming today and hearing about this and really sharing in our passion for stroke and exercise. So I just have to disclose no relevant financial disclosures. So why don't we routinely prescribe exercise? And so I really want to hear from the audience. You can shout it out. So why don't we prescribe exercise? What is it that keeps us from doing that? Nobody can be shy here. Paid for it? compliance. Okay, great. I love it. Even better. Excellent. Outstanding. So, when we look at these topics, we think about, you know, effective implementation. So to take something and to integrate it into the health system is very challenging to do. And I've really been, you know, excited to work with different leaders in the field on innovative health systems and really trying to think about how do we make changes? How do we implement changes? And so that is something we need to think about. When we think about exercise, again, not every place has the right equipment to do exercise or multiple exercise devices. There's a lack of knowledge. So, not everybody's comfortable prescribing exercises. You know, what do I do? How do I best do it? Certainly, safety's been brought up. So, our motto is no harm. Let's not do harm. And so, again, if people think, well, is this person safe? Are they not? Should I do this? And that can keep us playing it safe and not implementing exercise. And then the health system readiness. You know, are we ready for the change? Are we ready to embrace something that's a little bit different that we typically haven't been done? Time. Again, I hear this a lot from the therapists. I just don't have enough time. I got to get them out of bed. I need to do transfers. I need to get them ready. I don't have time for exercise. I hear that a lot. Cost. Again, does that result in payment? And then we have to always think about the local context. So again, do people have access to equipment or things that would facilitate exercise? So it's not uncommon that healthcare professionals underutilize it just for these various reasons. But everyone agrees that aerobic exercise is important. We all know that it does help our patients. It increases their endurance. They feel better after they exercise for the most part. But a lot of us don't really know or they say that most just use this health record and patient response. Not everyone uses an exercise test. And again, I'm not going to go into details about exercise testing, but it is an important step in thinking about that. So I've been really fortunate to interact with two groups. And so the first was this paper that came out in 2013. It was a survey of Canadian physiotherapists. And over time they looked at, they asked these questions about what are your obstacles as a neurophysiotherapist for implementing exercise in Canadian health system? And so the answers were cardiovascular disease. You know, they were uncertain if they should do that depending on the complexity. Cognition. I don't know if they understand how to exercise. Can they maintain the exercise? And then fatigue. My patients are tired. They, I can barely get them to get out of bed and do what I want and you're asking me to exercise them. So fatigue is an issue. And then when it comes to the environment, the lack of staff, there may not be a lack of time to do it. They're unsure of the screening tools and what to do. So that spurred some of us in the U.S. to ask these same questions. We modified it and we asked physical therapists across the U.S. what to do. Very similar answers. Cardiac concerns. Fatigue. Cognition. The environment isn't suitable. So again, when we think about these things, when we think about the how-to, I think about these a lot. So when I design studies, I really think about what are the barriers to context. How do I help physicians and physiotherapists, physical therapists, overcome these boundaries? When I do studies, I can't do the unwieldy because then it doesn't get implemented. So thinking about how can we implement things into patient care? And why should we do this? So I borrowed this slide from Jeff Saver. We're at the European Stroke Conference and Jeff, Dr. Saver, presented on some other findings in a study we were a part of. But look at this trajectory. We see that we've done such a great job of decreasing occurrence by 80%, but people living with disability is rising. And that's probably not surprising to anybody in this room. But a statistic that recently came out that was published in 2023, the ages of 15 to 49 years of age is the fastest growing group that are having strokes and living with disability. That's powerful. So if we have a large number of people, 15 to 49, having cognition, physical disability, unable to return to work, difficulty caring for children, what if they have to care for their parents? That's a lot of things that we have to think about. And so that motivates me to try to figure out how do we advance our field in stroke recovery? What can we do to make a difference in the lives of people living with stroke? So why exercise? So this paper came out a few years back and I was really excited by it. It's really text heavy and very molecular. But exercise changes 9,800, whoops, sorry, got to go back, 9,815 molecules on our body, whether they're upregulated or downregulated. It changes that many. And we know that exercise is good for us, whether we're getting out, moving. And again, I always try to stress to our patients, exercise isn't running the marathon. That's not what we're looking for here. It's movement. It's getting up. It's walking. It's going up and down stairs. How many people take stairs maybe instead of the elevator and go up two or three flights of stairs? Anybody? Okay, what do you do when you get to the top? I go into meetings, people are like, don't you run? And I'm like, stairs are different, right? So again, it's exercise. We're getting our heart rate up. We're short of breath. And so, you know, something that's really important to know is that there was some work that came out in 2002 from my good friend, Rich Macco. And they showed that stroke survivors work at 70% of their VO2 max, which means every day they're climbing stairs all the time, right? They're working hard. So it is important to build that endurance. I love this quote. If we could take all of the good things from exercise and package it into a pill, it would be the most widely prescribed medicine on the market. And that's pretty powerful, right? If we think about that, we, you know, it is really important. In fact, I have a colleague that's trying to create a pill and they're calling it Aerobix, A-E-R-O-B-I-X. If people aren't going to exercise, maybe we can give them a pill. But that pill is not going to move 9,815 molecules and upregulate and downregulate them. Sure, you'll get some benefit. But there's nothing better than exercise for the majority of the people. So why exercise and what do we think about that in stroke recovery? So what I like to think about is, and there's not enough evidence for it and we need more, but I like to think about exercise as if you're going to recover from something, right? You want that environment to be optimal. You want your body to be in as good of shape or as healthy as it can be. And I think of exercise as that facilitator. Can exercise help maybe prime the system? And that's not my area of research and we'll hear more from Dr. Linder. She'll talk a little bit of that. But we're thinking about sprouting, right? And I like the analogy to axonal sprouting and thinking about neuroplasticity and these things. But we need to create an environment, and so sedentary behavior, laying in a bed all day, not getting out, talking to people, not moving around. These things are hard and how do we get people to move? And I know it really is challenging the system, but something we need to think about. So again, I'm not advocating that anybody not take their medications. I think exercise and medicine combined together is what's optimal. But when we look at this study that was conducted, and this study, it is a little bit old and nothing's been conducted since. But if you look at exercise, I mean, it worked better than anticoagulants and antiplatelets. Again, not better than blood pressure medicine, but it has a more positive effect on that. And we do need larger studies to see what is the role of exercise in recovery. It certainly helps lower blood pressure. We have a lot of people in our studies that have to, again, maybe have to go to their doctor and be re-dosed on their medication for blood pressure because they're just doing so much better. So as Dr. Linder mentioned, in about 2010, the original publication came out in 2004. And I was like, we have to look at the evidence. We have to do this. So to put this in perspective, in 2002, exercise was still like, we were unsure if it was good for people post-stroke. It really in the 90s was believed, I mean, I feel so old when I say this. But in the 90s, it was still not accepted. It was like, it'll make people worse, increase their tone. So we are a young kind of avenue or research area on what are the benefits of exercise. We know they're good, but specifically in stroke. So again, when we think about this, this is taken from the American Heart Association. People with stroke should get 150 minutes of moderate activity or 75 of vigorous. And we can think about this, but what's important to note here is that the evidence that I put into that paper and what is here is based on what we should do for everybody. And people with stroke are not everybody. They have unique deficits. They have neuromotor. They have cognition. They have hemiparesis. Maybe they have hemiplegia. There's just a lot of things that are different. And we can't use those because we have to know what can people do. And so again, this panel is so exciting for me because we're all trying to figure out how do we move the field forward? How do we break down barriers? And how do we think about exercise? When we think about intensity, this is a, whoops, wrong one. This is an important question because we have to think about this. If we think about intensity, intensity is the single driver for changing cardiovascular health. It is intensity. More so than duration and more so than other prescription parameters. Intensity really is important. At the bare minimum though, sit less and move throughout the day. There is, again, not everybody can exercise. Not everybody has access. So messaging to sit less and move more is really important for people if you're sitting all day long. Okay. Are we going to be good with our? All right, we'll try it and see. All right. So high intensity interval training. This is something that has really come to the forefront of exercise. And this is a big leap, right? I mean, when I think of where we were in 2010, 2012, 2014, we were putting these guidelines out. It was, ew, it was moderate intensity safe. And now we're at, and now we're looking at what should we be doing for HIT, right? And this is something really important. Am I good to go? All right. So, but where's my, the QR code is now gone. Oh, you know what? You might have to, but they can't get to it. Yeah, they won't be able to get to it if we don't have the QR code. So if you have pull everywhere, you could log into this or I could just do a raise of hands because I don't want to cut in on other people's time. So look at those questions. And if you're comfortable, I'm just going to ask, the reason I want this is because there's a poll at the end and I wanted to take this and I wanted to think about your answers and I wanted to see how many people were really comfortable. So if we can kind of just be honest and open and wonder how many people are absolutely not comfortable prescribing HIT for people post-stroke? Let's be honest. We have a few people, hands, okay. So I might call on a few people and ask you how you do it if you don't raise your hands. All right. How many people say, I need guidance to do HIT? Ah, there we go. We need some guidance. Okay, great. How about, I'm somewhat comfortable prescribing HIT? Anybody? Any takers? How about, I am highly comfortable, oh, we've got some coming in, highly comfortable prescribing HIT for most patients? Oh, we have a few takers. Okay, nice. Outstanding. All right. Well, you guys can keep answering and keep bringing them in and if you have Poll Everywhere, go ahead and do that. You can also log in to Poll Everywhere if you want to and just skip all of the, I need my name and all of that stuff and you can go to that Poll Everywhere. But as many responses we can get would be great because I'd love to think about this. All right. So in case you're not sure about HIT, it's really about this repetitive switching. And so when we think about this switching, thinking about high intensity or passive recovery, we can do short interval or long interval. So I'm going to ask. So my two sessions combined, I have 25 minutes, right? Okay, because it's given me a one minute, or I have a red flashy light. Okay, so I'll, yeah, I just, I think we put two of mine together. Okay, so the high-intensity interval exercise, so again, we need to think about this as, again, it can be high-intensity or sprint interval, and again, this isn't for people with stroke, but if you've seen sprint intervals, some people go all out on these, and that's not what we're talking about here today. You can do active recovery or passive recovery, and this really means that sometimes people stop exercise and just let them rest, and there's been some thought that people with stroke need more recovery time. I will be honest, I'm not an advocate of just stopping, because I always think of venous pooling, and then, you know, you got to start from being cold, like you just stopped and then to start. So I really like a more active recovery, so decreasing the watts and looking at that to prescribe exercise. So again, you can have short intervals or long intervals. How many people have done long four-by-fours? Raise your hands. Oh my God, you guys are amazing. I get to like two minutes and 39 seconds, I'm like, I'm done. I just did, the four-by-fours are really hard for me, but I really like the one minute on and one minute off, and so I've practiced all these different intervals, and I'm like, I can do one minute. I can give a pretty good all-out effort, because then I know I only have to do it for a minute and I get a rest, and so this is the work that we do. We do a lot of short interval one-by-tens or one-by-fifteens. Low volume means you're doing your hit less than 15 minutes, and high volume is greater than 15 minutes, and so this is kind of what the shorter look like versus the longer hit. We know in healthy people that shorter exercise time, it's attractive because people don't have time to exercise always, and again, there have been some studies that show there's been weight loss, better blood pressure control. Even in cardiac patients, there's better blood pressure control, better peripheral vascular function, so I'm guessing this is using either an RTO stiffness measure or flow-mediated dilation, and then fitness, so your VO2 max, your VO2 peak measuring aerobic fitness. So within stroke, what we see is that hit is beneficial for walking outcomes. There's been multiple multi-site trials or pre-post looking at walking outcomes, and this could be the six-minute walk or it could be gait speed. It overcomes time barriers, so again, if you can get the benefits of 40 minutes of that exercise and you could do it in 10, why not? We also see that fitness is moving really nicely, so we're building people's endurance, and when you build their endurance, they actually work at a lower effort, and what we see is that compared to moderate continuous training, there could be some benefit for motor learning, neuroplasticity, corticospinal excitability, but we need more trials. We need rigorous randomized controlled trials if we're going to do that. So one of the things that I was really interested in is thinking about, you know, again, as a physical therapist, I think about function a lot. You know, they're walking, I've been trained to think about balance and these things, but I'm also very interested in what happens to the brain, so I'm going to share some work that we've been doing. So I read this article in 2015 that was presented that says, should we be hitting our brain? And I thought that was really kind of interesting. It's like, is it good for us? Because again, you're running all out, and then you're stopping, slowing down, you're running all out. If you're doing those, you know, one-bys, you know, one on, one off, one on, one off, that's a big change in your blood pressure, and then it's dropping, and then it's changing. And so, in this paper by Sam Lucas, he wrote, should we be doing this in people with stroke? We don't even have clinical trials showing that there's no damage to the brain, and it's already being implemented, and there's a clinical practice guideline. Should we really be doing this? And I went, wow, that's a great question. Like, we have the technology. We could ask this question, and should we be hitting the brain? And so, when I think about all of these mechanisms here, it's like, you know, you could think about cerebral pulsatility, mean velocity, blood flow with the MRI scanner. We can look at endothelial function, arterial stiffness. So, these tend to go down or improve with exercise training, but we haven't really looked at, you know, sex hormones, age, and blood pressure as mechanisms to really see if we can benefit or if there's harm to the brain. So, when we think about this, you know, units are often on acute and inpatient rehab units are often sedentary. So, we need to think about this, and we propose using middle cerebral artery velocity with transcranial Doppler ultrasound to do this, because you can get at the dynamic measures. You can't really do all-out exercise in a scanner. And so, people living with stroke have a high risk of dementia and could exercise. Again, if we can get people to do this, would this be better? And so, we really need to understand their cerebrovascular health post-stroke, and then the implications of therapeutic interventions such as HIT. So, this was Allison. She was a Ph.D. student. I think this was like the day before her dissertation. She needed a picture. She, we did HIT training on a recumbent stepper. We measured their blood pressure with each heartbeat. We measured transcranial Doppler ultrasound using TCD to get at their brain blood velocity. We use an EKG for heart rate, and then really nobody's smiling when they do this, but they have a nasal cannula for, to measure CO2. And so, what she really wanted to look at is, should we HIT the brain? What does blood pressure do, and what does heart rate do when we're doing HIT? And this is in chronic stroke. So, her protocol that she published, we were getting baseline data for all those variables. We started with rest, or I'm not sorry, not rest. We started with a recovery interval. And so, again, if you valsalva or push real hard, your blood pressure drops, your brain blood flow drops. So, we started with kind of a warm-up just to get them going before we did the HIT vows. And we did 10 minutes of this. We did a cool-down, an active cool-down for 10 minutes, and then we, I won't present this data, but we did a 5-minute recording, and then also 30 minutes after. And so, this was 5 minutes after, and then 30 minutes after. And so, we were switching between this 1 minute on, or 1 minute off, and 1 minute on, and really wanted to see what these data looked like. So, in our sample here, we did individuals post-stroke and then controls. And we looked at, you know, fitness, and we looked at statin medication. Of course, the stroke patients were on more, our participants. They had greater arterial stiffness. So, really at about 10 or 12, this is, these are, that's not a good marker. So, we had a few, but the average was 9. We do, I just want to point out that their watts are different. So, these people are working at different workloads. So, when you're interpreting the data that I'm going to show you, just keep that in mind. But again, that's not surprising because people with stroke are deconditioned, although the controls were sedentary. They had to be not meeting minimum guidelines. Recovery watts were pretty similar, but again, just trying to get people based on their exercise test, their wattage was a little bit lower. But interestingly, they rated their perceived exertion almost identical. So, that's really interesting. So, what does this look like? So, for the controls, which are the open circles here, we see that, you know, here's their response to hit. So, with their first from baseline, we go up to that recovery bout, blood velocity increases, and then the hit bout, it goes up, but then you can see it starts to fall just a little bit as they start to hyperventilate, but here's their response. The stroke contralesional hemisphere response is not as quite as good as the controls, but it's certainly better than the stroke affected side, which is not surprising. So, the data show that the ipsilesional stroke side and the controls are significantly different at all time points, but not for the contralesional. We were probably underpowered to really look at group differences for this variable, so just kind of keep that in mind. When we looked at that movement, I just wanted to show you, like, for both of the groups, their arterial stiffness was related to whether their middle cerebral artery was flexible with that response, and you might say, what does that mean? Well, we also looked at this in Young Healthy data. See how their middle cerebral artery velocity goes up and down? So, with rest from baseline, we go up, and then here's a hit bout. Here's a rest, and it bounces up. It drops with the hit bout. It goes back up and goes down. So, you can see the healthy people have this nice kind of up-down response, whereas if you think about our stroke side here, not quite as much, but neither did the controls. So, there really is something. These were all active individuals. So, really looking at does arterial stiffness or lack of flexibility in the blood vessels and blood pressure kind of limit that responsiveness or that regulation of blood flow? And so, that's kind of an interesting takeaway that we had. But one of the things that we really wanted to look at, too, was what does their blood pressure look like? Are they reaching targets that are not acceptable by ACSM standards for being too high or too low in that response? Do we have people go hypotensive during those responses? And so, we're happy to say that diastolic blood pressure really maintained, and I just want to note, you might think, well, this is really low for, you know, maybe diastolic pressure. We're using that finger cuff, so it is slightly lower than when you take it at the arm. Just kind of think about that. But we didn't have anything that was reaching our criteria for cutoff for safety. So, the one-bys and chronic stroke really seem to work if you prescribe it accurately. And here's the heart rate response. So, again, we see that people with stroke actually do have this nice up-down response. They're responding appropriately with the heart rate. We just see a different response with the middle cerebral artery velocity. But they are getting their heart rate up there. They did reach the target of 77% of age-predicted heart rate max. We had a little bit different range. We were a little conservative in this study just to start out, and we're a little more aggressive now trying to get them to 85%. So, we're prescribing a little bit different for a randomized double-blind trial that we're doing. So, in chronic stroke, it appears that HIT is safe from a hemodynamic perspective. Again, we screen. We make sure their meds are stable. And this is for chronic stroke. We see that the MCAV response during HIT is reduced when we look at normal controls. And then when we think about the interventions that are needed to determine about HIT, I talked about FAST, and this is our double-blind RCT where we're comparing moderate continuous to HIT. We're doing a four-week trial, and we're prescribing on a recumbent stepper. Not everybody can do treadmill training. Not all places have access to that. So, we want to be inclusive when we think about these things. And then Dr. Wingard, she's out there in the middle. All right. We've convinced her that she needs to look at the HIT on the inpatient unit. So, she has a project that she's doing that we want to see if this can translate to safety. You know, again, we've shown safety in chronic stroke, but can we do this during inpatient? And I think influencing change time is now... I had the privilege of going to Singapore to work with a physiotherapist there. They are really doing great work there. Their inpatient is now doing exercise testing. I went over there and trained them on our exercise test. They're implementing it into inpatient rehab, and they're bridging a gap to the community so their patients don't feel like they're just, I don't know what to do. I'm down, done with rehab, what do I do? So, I'm really impressed with her. Mary Morafferty at Shirley Ryan Ability Lab, they were, during COVID, doing exercise testing in inpatient rehab. I'm excited to see some of this. They did it on everybody, on a lot of different groups. And so, they've been presenting data. And then you're going to hear from my speakers here. Again, they're moving and pushing the boundaries. We need to look at the evidence and push this forward. We have to collaborate, learn, and think outside of the box to be able to have win-win solutions. And with that, I'd like to thank everybody. Are we holding questions until the end? All right. Thank you all. Thank you. Perfect. Great, thank you. There we go. Great. Thank you, Dr. Billinger. I am going to transition a little bit and talk more about the neuroplastic effects of aerobic exercise. And I want to, oops, let me go back. I want to set this up a bit before we start. Introduce this video a bit. In 2010, I changed from full-time clinical practice to working in a research lab. And at the time, the PI I was working with was looking into the role of aerobic exercise in mitigating symptoms in people with Parkinson's disease. And this video fundamentally changed the way I think about aerobic exercise. And it really led me on this trajectory of investigating how aerobic exercise can have neuroplastic effects. So this individual has Parkinson's disease. He was an avid cyclist, and he was no longer able to cycle distances because of his disease and his symptoms. He happens to be a movement disorders neurologist that the PI I worked with worked with. And he had a deep brain stimulator. Since he was no longer able to cycle, my friend invited him to go on a week-long bike ride across Iowa on a tandem bicycle so that he could still get the benefits of cycling but didn't have to have that power output. So he did this, and this is just a video of him when he turned his DBS off and the symptom improvement. So again, this is off DBS. This was a tablet PC where they were just doing a line tracking. So that to me was telling me that something is happening here, right, physiologically, neurophysiologically. And we have the opportunity to harness this benefit. So this is a little model that we created, a schematic, to try to understand what might be happening. And in this case, you know, it was probably dopamine, I think we can agree, to some degree, that was reducing this individual's symptoms. But there's so many other, through animal studies, so many other physiological processes that really have the potential to harness neuroplasticity. And this is what I've spent the last 14 years of my career investigating. I'd like to share that with you. This is a systematic review that looks at, mostly in animal models, but also in some human models, what the exercise-induced response is to specifically brain-derived neurotrophic factor. And BDNF is really a building block of neuroplasticity. It's a protein that's upregulated with exercise. And higher intensity training, like Dr. Billinger was noting, is what elicits a greater response. It is thought that you need BDNF in order for neuroplastic change to happen. So there have been animal studies where they've actually reduced BDNF, and animals don't recover as well after a stroke. So BDNF really is one of those critical proteins that are necessary for neuroplastic change. So I'm going to talk a little bit about facilitated exercise. And you saw in the model how this started out. Individuals with Parkinson's disease, or MS, or stroke, probably lack that voluntary exercise effort at some point to achieve consistent, high-intensity exercise. And this is what we thought at least 10, 15 years ago or so. It has been shown, though, that some are able to do it. But there certainly is some element of weakness and lack of cortical control that might limit their ability to, again, have this continuous active exercise output. So we initially used a tandem stationary bike to facilitate exercise. And that was later translated to a custom-designed motorized cycle. And now there are two commercially available motorized cycles. So this is what we use in our trials. It's important to note that these are designed really to overcome the barriers to intensive aerobic exercise. But patients are not passive. So they don't just sit there and let their legs have spun or be spun. They wear heart rate monitors, chest straps, and we make sure that they're in that 60 to 80% target heart rate zone. So I adapted this model that was initially designed in Parkinson's disease to people with stroke using aerobic exercise as the primer, combining it with active rehabilitation in order to improve outcomes. About a year and a half ago, we completed a four-year trial enrolling 60 people with chronic stroke. We were looking at upper extremity motor function, excuse me, upper extremity motor function, quality of life, and walking outcomes. And we had two groups. One group completed 45 minutes of facilitated exercise on that motorized bike, followed by 45 minutes of upper limb repetitive task practice. The other group did not partake in aerobic exercise, but instead did double the dose of rehab or double the dose of repetitive task practice. And again, our hypothesis here was, can we use aerobic exercise to prime the brain and shorten the amount of rehab that's necessary to produce motor recovery outcomes? Our intervention was three times a week for eight weeks. And the aerobic cycling group did do about 45-minute sessions. We were close to that 60% target, but we didn't quite reach it. It was 56.4% of their heart rate reserve. And they did about 37 minutes per session of upper extremity repetitive task practice. So here you can see the facilitated or aerobic exercise group. And the repetitive task practice only group did 90-minute sessions, so understandably they did about double the dose of rehab. Despite the double the dose, both groups improved comparably on the Fugl-Meyers score. So this is the facilitated exercise group at baseline end of treatment and one month following. And the repetitive task practice, or the rehab only group. So while we didn't measure mechanistic outcomes to see if aerobic exercise did truly prime the brain, our clinical outcomes do support that hypothesis. Next we looked at change in cardiovascular function. We conduct metabolic stress tests on everyone at baseline and at end of treatment. And we saw significant improvement in peak VO2. And mind you, this is only an eight-week program. So it's a really limited intervention. And I'm certainly a proponent, not only for longer interventions, but really for lifelong aerobic exercise. And we'll talk about that in a bit as well. In addition, we administered the six-minute walk test and we also measured gait velocity. We've done some biomechanical gait testing as well. I still have to look at those data though. We saw significant improvements in six-minute walk test outcomes for those who did the cycling intervention compared to those who did not. Similarly, we had significant improvements in gait velocity. Now mind you, this is a cycling intervention. We did absolutely no gait training. So this is a really important finding because there's a thought that if you want walking to improve, you need to train walking. But we're showing that there probably is a similar enough spatial-temporal and kinematic requirements in cycling that it carries over to walking without the stress of high-intensity gait training. Just wanted to show you, like I said, we did measure gait biomechanics. So this is just one participant's before and after. You see that the mechanisms are still there. Some of the compensatory strategies. But what we are finding is patients are not compensating more in order to walk faster. Their gait biomechanics are actually improving. So that's an important aspect that we're really driving change in locomotor function. And again, not just more compensation. We are just embarking on our next trial. It's called iSCORE, where we're looking at, excuse me, looking to see if aerobic exercise can again reduce the dose necessary. We're looking at PT and OT in subacute patients. And this is a pragmatic study, so it will be in an outpatient rehab environment. This is the model I showed you earlier. We have already have outcomes both in cognition, motor control, and some in mood. But this time what we'll be doing is we'll be looking at the mechanistic outcomes as well. So we'll be measuring EEG before and after, and we'll be measuring BDNF and IGF to see if there are blood biomarkers that change as a result of the aerobic exercise intervention. So this is a four year trial. We expect to enroll 66 people. And people will either get the facilitated exercise and abbreviated sessions of PT and OT, or full sessions of PT and OT. And this will be two times a week for 12 weeks. Again, looking at subacute stroke patients. Sorry, one more important thing. We'll be looking at a cost effectiveness analysis as well. And this just goes to the panel's commitment to advocating for our patients and driving policy change. Because really without that some of those concerns that people brought up with cost and such can't be addressed. And to look at just the continuum of care, as Dr. Belanger mentioned, after people are done with rehab they really don't know what to do. You can't just prescribe them go to Planet Fitness or go to Orange Theory. It doesn't work for this population. Aerobic exercise is a skilled intervention in this population. And I can't underemphasize that. So we have a community-based pro bono exercise class that was funded by our philanthropy that's supervised by both therapists and exercise physiologists. And we find that this is a really great bridge from the outpatient rehab environment to a community-based program. And they're in the program for a few months, supervised, taught how to accommodate to their disability. And then they transition to independent community members. And we have found this to be a really nice transition to really get people on the road to long-term recovery. Thank you very much. Okay. Welcome everyone. We're very excited to be here and to hear the amazing work that Dr. Linder and Dr. Billinger are doing and to know that everyone in this room is advocating for this type of work and really out there, you know, getting really trying to build this program for our stroke patients nationally. So we're here to talk to you about the work that we did. And I'm here with Dr. Talia Fleming. So, and we're going to be talking to you about the effects of a comprehensive stroke recovery program on modified cardiac rehab and the drive to change reimbursement policy. So we have no disclosures to announce. As far as the learning objectives, we're going to be talking about the review of stroke care and recovery. That's a national problem, which is projected to get worse. That the stroke recovery program takes a proven model used in cardiac rehab and improves healthcare delivery for stroke survivors. We're going to review the stroke recovery program and shows its benefits for function, mortality, re-hospitalization and cost. We're going to address that stroke post-care acute programs deserve the same healthcare delivery options that we know work extremely well for the cardiac rehab population. In 2016, the American Heart Association and the American Stroke Association put out guidelines for adult stroke rehab and recovery. And they found consistently that patients who comply with inpatient rehab should go to inpatient rehab. And that's about 22% of the stroke population that comes into the acute care hospital. And that's in preference to sending them to a SNF or a long-term care facility. And they found that the patients who comply and go to inpatient rehab have much higher rates of return to community living and greater functional recovery. And those that do not, those that are shipped off to a skilled nursing facility or long-term care facility, they end up having much higher re-hospitalization rates and substantially poorer outcomes. The journal... And once they leave inpatient rehab, they need to make that transition to outpatient rehab and really need that to continue and complete their recovery. And in the Journal of Circulation, an article was published showing that only 30.7% of all those patients that go to either the acute care hospital and go home or go to the acute care hospital and go to inpatient rehab and then try to transition, only 30.7% of them actually make that jump. And that's much lower than we would expect as PM&R docs. And what ends up happening, if these clinical practice guidelines had been followed, that patients would do much better. And they have certain barriers. And one of the barriers that really challenges our stroke population is funding. So one of the things we want to touch on is that CMS has, as many of you know, either a Medicare therapy cap or a Medicare therapy threshold where when they transition into outpatient therapy, they're challenged with co-pays, they're challenged with this limited cap or threshold which only accounts for $2,000 for PT and speech combined and $2,000 for OT services. But there are medical diagnoses that are excluded from the Medicare therapy cap. And these include cardiac and pulmonary rehab program, where they get this very robust, comprehensive outpatient program once they have a cardiac event. So we're going to talk specifically about the cardiac population. And here are the compliant diagnostic categories that once a patient has an acute MI, if they have a stent placement, if they have a stable angina that meets the requirements or cabbages, they get this robust three to four month program that gives them a whole host of services. And these cardiac patients benefit them purely on the fact that there's data been produced that shows that this program truly helps them. In 2011, Mayo Clinic did a study on over 2,300 patients post-PCI or stent placement, putting them through this comprehensive program. And this comprehensive rehab program included 36 sessions of interval cardiovascular training, rehab risk factor management, rehab psychology, nutritional education, medication management. And it found that after PCI, that there was a 45 to 47% reduction in five-year all-cause mortality as compared to those patients that did not do cardiac rehab. This was groundbreaking. And this is a YouTube video. And if you watch this YouTube video, this gentleman, who's part of this, Dr. Gold's part of this study, said that if someone was to come up with a pill, talking about what Dr. Linder said, someone was to come up with a pill that reduced mortality 45 to 47%, they'd win the Nobel Prize. So in this, this, you know, and because of this and because of the data produced from these studies, Medicare fully funds cardiac rehab for cardiac patients. The goals of cardiac rehab are very straightforward. They're to maintain or improve function and cardiovascular fitness, to reduce the risk of future cardiovascular events, to improve modifiable risk factors, to make sure that the patients through those first three or four months post-event are adhering to medication regimes, improve quality of life. And again, it's not just for the three to four months, but to adopt lifelong healthy behaviors where they'll continue to do this and decrease overall mortality at five years post-participation. It's important to know that stroke is a cerebrovascular disease with neurologic consequences. Right now, CMS is only funding neuro deficits that, as part of, as part of the patient's strokes, which includes weakness, balance, coordination, vision issues, swallowing issues, and that's with our traditional neural rehab model. And in our research, we're seeing much greater benefits overall for stroke patients with their cardiovascular health also being treated and addressing the cardiovascular risk factors and health through a cardiac program because the vascular system is all one system. So if you're getting cardiovascular health, in turn cerebrovascular health is also being impacted. But what about our stroke patients? Instead of having a heart attack, they're having a stroke or a brain attack. So these patients recovering from stroke must use the Medicare funding within the Medicare therapy cap for outpatient therapy because we, no big multi-center studies have been done to produce data showing that this truly helps stroke patients. So this puts our patients at a disadvantage and during their stroke therapy, and again, sets them up for a second event. So with patients with stroke, as we well know, have many of the same risk factors as cardiac patients. They have hypertension, diabetes, hyperlipidemia. But again, our stroke patients are even more challenged because not only do they have all of that, they have functional deficits including dysphagia, aphasia, hemiplegia, cognitive deficits, and spasticity. So we decided that we wanted to try to accrue this data showing what we believe will really move strokes forward because of their cerebrovascular disease and the fact that attending to their cardiovascular functioning will also help. So we went on to develop the stroke recovery program and now I'll have Dr. Fleming talk to you a little bit about that. Thank you. So the foundation of our program really starts with an outpatient physiatry visit. At that visit, the physiatrist will recommend and order physical therapy, occupational therapy, and speech therapy, depending on the patient's needs, traditional for neurorehabilitation. What we included was this special mini cardiac rehab group or cardiovascular conditioning group. And that was designed very similar to cardiac rehab where we administer it three times per day for up to, I'm sorry, three times per week for up to 36 different sessions. At that physician appointment, we also have an opportunity to talk about nutrition. We talk about rehab psychology and neuropsychology. We talk about specific stroke specific education. So what are the warning signs for stroke? What are needed to, what do you do in the case of an emergency? We do a mood assessment. So again, a comprehensive look at how we take, how we administer post-stroke care, not only focusing on the rehabilitation, but focusing on the whole individual. In this mini cardiac rehab group, remember Dr. Puccarulo and I were out, we were talking about this and we talked to neurologists and cardiologists and internal medicine. And many of their questions were, well, how can someone with a stroke even exercise? They can barely walk. How are you going to have them exercise? And our response was we're physiatrists. We do this all day, every day. We make modifications for people so that they can participate in a particular activity. The most common challenges that we found were weakness of the one side compared to the other, trouble with cognition and attention, poor safety awareness, post-stroke fatigue, which we know is very common, as well as cardiovascular instability and other comorbid conditions like underlying either lung disease or underlying arm arthritis. And it's interesting that Dr. Billinger, your initial questions were, what are the reasons why someone isn't prescribing exercise? And it's interesting that we actually addressed all of this within our particular program because we felt that that was important. The mini cardiac rehab group is an interval cardiovascular training on a recumbent cross trainer bicycle. We wanted to make sure that this was more than just sitting someone on the side and having them exercise at their own pace. This is literally interval cardiovascular training. We decided to use a recumbent cross trainer bike for many of the reasons that we mentioned earlier in terms of safety of administering the exercise and having it be consistent throughout the group. Every single person who comes obtains cardiac clearance before they start the program. And being that this is administered shortly after their stroke, we decided to start with that low to moderate intensity program, and then they advance throughout the 36 sessions. What's interesting is that we have about a one to two ratio of staff member to patient, and it's usually administered there with an exercise physiologist. And what's happened is that they've formed their own mini support group. So they're sharing secrets, they're supporting each other, they're encouraging each other. So that was another added benefit just by having this specific carve out of a program. So we decided to, we thought of this idea, we found that there was a gap in care, we developed this program afterwards, and Dr. Kukurilo and I said, well wait a minute, why don't we collect data? What if this can be the linchpin, the key to explain to everyone else the fact that this is important, that this works, and that we need to take this to the next level. So initially our goal was to really look at this and collect data so that we can prove to payers the fact that patients with stroke, they're not trying to game the system by getting extra rehab, they're just trying to get better. It's important for us, especially as we know that more and more care is being pushed from inpatient to outpatient faster. We need to beef up our ability to provide these robust outpatient programs. So we decided to design a clinical trial. We did a combination feasibility study just to look at whether or not this was feasible, and then we also did a subgroup analysis. What we did was we took patients that were admitted to our inpatient rehab hospital, they went through inpatient rehab, and then upon discharge they were, they were, went into two separate groups. Our non-participant groups were the people who got discharged from the inpatient rehab hospital, they went back to their primary doctor or their neurologist. They were the usual care group. They, some of them did get therapy, some of them didn't, but this was to represent typical post-stroke care the way that we currently do it. Our participant group were the ones that we had come back to our facility, and they had this comprehensive program where they not only saw the physiatrist, they had their comprehensive neuro-rehab, and they had their mini-cardiac rehab at our institute. So the following demographic table shows that we did the feasibility study, and that was on 136 stroke recovery patients. And then we also did, you can see in the second column from the left, and then we also did a randomized matched subgroup analysis on 76 matched pairs. And we modeled this after how the Mayo Clinic did a matched pair analysis, and we matched on gender, we matched on gender, race, and type of stroke, and age, discharge impacts, and comorbidity index. And even though we didn't match on comorbidities, we did not see any significant differences in the matched groups in all of these areas that you see off to the right, the column off to the right, except in smoking, we did see a difference with that. We went to great lengths to make sure that both groups were similar at baseline. So regarding the feasibility study with the stroke recovery program data, one of the key things, because we were doing this 30 days plus or minus 15 post the acute stroke event, we found out that the, we found with cardiac clearance that this was safe, which was very important to us. We got, again, cardiology clearance on every patient that entered into the program. And interestingly enough, with that clearance, some patients were excluded because the cardiologist did stress tests and said that they needed to get full cardiac workups. Another very interesting thing is even with cardiac clearance, with these people that went through the program, four patients, once we, as we stressed them and put them through this program, told us that they either had some chest tightness, some left arm numbness, and four patients we sent back to their cardiologist and they required stent placement. So cardiac disease is a very prominent issue that our stroke patients have to deal with, and that's something to keep in mind. We also found an improvement in exercise duration. We found an improvement in exercise capacity, and we measured this in met minutes. We, if you look, you'll see at the start, at the baseline the average met minutes was 46, and by the end of 36 sessions, the three to four months, it elevated to 95. And if we switch that over to percentages, we saw that there was an improvement in their exercise capacity of 103%. So we're taking you on our journey. As you can imagine, we're really, really excited. We've had this idea. We're starting to get some feedback in terms of data and in terms of the improvement of their cardiac capacity. Next, as physiatrists, we wanted to take a look at their overall function. We decided to use the AMPAC, or the Activity Measure for Post-Acute Care, several reasons why we wanted to do that. One of the main reasons was because it breaks function down into different domains. Basic mobility is a measure of physical therapy skills. Daily activity is a measure of occupational therapy skills, and applied cognitive is a measure of speech therapy skills. So we know that the modified Rankin Scale is a very limited scale, even though the neurologists love it, stroke world loves it. We wanted to take that a step deeper. An additional reason why we wanted to use the AMPAC was that it was a certified tool that Medicare approves in terms of taking a look at specific outcomes. We know that in rehab there's lots of different ways to measure different things. The AMPAC is a measure that has been proven not only in the hospital setting, but also in the skilled nursing setting, also the home care setting, as well as the outpatient setting. So we wanted to track our patients over one year and see how their function changed. The AMPAC also gives you a numeric score where we can track that over time. This is an example of some of our results. As you can see on the X axis is time. So we take the initial score on the admission to the rehab hospital, on discharge to the rehab hospital, and then at 30, 60, 90, and 120 days post-stroke. That 30 day to 120 day is usually when they're in that comprehensive outpatient program. So that was where we wanted to take a look and see about that specific intervention. On the Y axis is the AMPAC score. So the higher the score, the more function the person has. As you can see on the bottom line, that's the non-participant scores. And then on the top line is the stroke recovery program participant scores. As we can see between both, from admission to discharge to the rehab hospital, they both perform about the same. That's expected. They're both in inpatient rehab. Upon discharge around that 30 day time point, that was where the graph starts to differ, where we can see that the non-participants improve, but not at the rate and not to the total amount that the participant group was able to show. And remember that participant group was the ones that came back to the rehab hospital. They had the neuro rehab as well as that mini cardiac rehab. And we see that there's a statistical and clinical difference between their endpoints. So it's a difference between someone who's participating in the community, ambulating, usually without a device, compared to someone who still may need some assistance in their ambulation. We took a look at the daily activity as well. This is a measure of primarily occupational therapy skills. And again, we see that similar trend where on the inpatient rehab hospital, they both performed about the same, but by the end of that 120 day time point, there's a statistical and clinically difference between the groups. And this is the applied cognitive scores. Again, similar difference, not as robust as the other, as a PT and OT skills, but we also know that cognition changes more of over a longer duration of time. So we weren't surprised that by the 120 day that they didn't reach their maximal difference. So regarding the one year all cause mortality outcomes for the matched pairs, when we compared the two groups, if you look at the pie graph off on the top to the right, the non-participants had 10 deaths, or 15.2%, and the stroke recovery participants had one death, or 1.3%. And after fitting a Cox proportional hazard model, the results of this model suggest that the non-participant group had a 9.09 times higher hazard of mortality than the stroke recovery participant group. Regarding the feasibility study, the Journal of Stroke put out an article showing that the all cause one year mortality of stroke patients in the U.S. is about 31%. And when we looked at the all cause mortality of the stroke recovery participant group, it was 1.47%. So this was published in the American Journal of PM&R, and the conclusion showed that stroke survivors receiving a stroke recovery program integrating modified cardiac rehab may potentially benefit from reductions in all-cause mortality and improvements in cardiovascular performance and functional performance. And with this article, we were awarded the Excellence in Research Writing Award, and this was very important, because from this article being published and us receiving this award, we were offered an invitation to the Medicare Innovation Center to present this data to the Medicare Innovation Center. So, we were very grateful that it got Medicare's attention, because we all know we need funding to run programs like this. So, as you can imagine, we're super excited. Medicare's inviting us to come down. We're getting closer. We're getting closer. They thought that it was a great idea. It makes sense. Why aren't we doing this? They gave us some homework to do, though. They said, number one, can you prove that the Stroke Recovery Program saves money? They said, two, can you statistically validate your previous improvement in mortality, meaning can you still enroll more patients? We want to see a larger sample size. And then, can you also replicate this at other institutions nationally? So, Dr. Cucarillo and I, we said, let's take this challenge on. One of the reasons why Medicare wants us to take a look at money is because the cost of stroke is expected to soar over $240 billion, and that's by the year 2030, and that's an underestimation. So, we propose that what if we change how we think about post-stroke care? What if the patient gets admitted to the acute care hospital, afterwards they come to an inpatient rehab hospital, especially for those who are candidates for it, and then afterwards it becomes a standard of care that they're discharged to this outpatient stroke recovery type of program? What would that look like? So, we took a look at our data again. We matched our pairs based on our previous analysis, and this is what we found. So, again, knowing that Medicare was very interested in cost, we compared the non-participant group to the stroke recovery participant group, and we see from a readmission standpoint that the stroke recovery participant group had a 22% lower risk of all-cause readmissions as compared to the matched non-participant. And in looking at this, that converted to cost savings. So, if we compare all annual stroke admissions, which we know is about 795,000 strokes a year, and should they all do the stroke recovery program, and we look at both groups, and we see this 22% reduction in readmissions, this could save Medicare, with the cost of an average readmission being about $14,000 per year, this could save Medicare, if every stroke did this program, about $1.12 billion in readmission costs alone. But we all know in this room that every stroke can't do this program, so we said, let's just look at the group that we did in our program. So, if we look at only stroke admissions that go to inpatient rehab, that 22%, and we have that 22% that have strokes and end up in rehab, and end up in our IRFs, and we reduce their readmission rate by 22%, that alone, with just the patients that go to IRF, would save Medicare an average $200 million alone in just readmission rates. So, that again, Medicare was very concerned about cost savings. So, this is a general comparison cost of what the program cost us through the trial. And we went on to publish this in the American Journal of Physical Medicine Rehabilitation again, with the conclusion that acute care hospital readmissions were reduced by 22% in stroke survivors who participated in a stroke recovery program. So, as you can imagine, everyone's excited about the reduction of 22% of hospital readmissions. But we took a look at that, and not only in hospital readmissions, but there's other cost savings too. So, for example, having someone go to a SNF or requiring additional home care services are additional costs, whereas through the stroke recovery program, if we help them to improve their function, there's overall less healthcare utilization. So, next, Medicare, the second question that they asked, can we statistically validate our improvement in mortality? Again, we took a look at our previous sample size, we added more patients, and these were our results. Our Kaplan-Meier, this is the Kaplan-Meier curve, and as you can see, there was, when we took it, when we brought the study to its full power, we had an estimated reduction in one-year all-cause mortality of 76.5%. If you look, Dr. Fleming talked about the AMPAC scores. If you look, we consistently had improvements in all three domains of the AMPAC, basic mobility, daily activity, and applied cognitive, which went through when we reached the full power. And our cardiovascular improvement, you'll see that that overall, when we brought the study to its full power, improved at 78%. We went on to publish this in the Journal of Stroke and Cerebrovascular Diseases, and the conclusion was, stroke survivors who participate in a comprehensive stroke recovery program incorporating modified cardiac rehab had a four-fold reduction in one-year post-stroke mortality, as well as improved overall function and improved cardiovascular performance. So, the third piece of the homework assignment was that we replicate the stroke recovery result at other institutions nationally. So, we are going on to do a randomized controlled clinical trial at a multi-center level, and this was important to us in implementing the cardiac rehab program for stroke patients so we can prove to CMS that the diagnosis of stroke should be added to the approved CMS diagnostic categories, or that it deserves its own program, much like peripheral vascular disease, for the SET program. As we know, congestive heart failure was recently added to the list of compliant diagnostic categories due to the data that was produced from the chronic heart failure trials. So, we said we wanted to do the same thing. And in general, as we said, these are the diagnostic categories that are approved for cardiac patients now. And now, in 2017, peripheral vascular disease was added as its own program for the SET program. So, we feel very strongly that with our stroke patients having cerebral vascular disease, they deserve that same type of consideration and program to be funded for this. So, we're moving forward. JFK Johnson is partnering with several other facilities. You'll see Muyano-Park here from Burke Rehab, Preeti Raghavan from Hopkins, Carmen Turcic from Mayo Clinic. We've also added Bu Nijin from UAB, and Nicole Mawazi from University of Washington, that we're moving forward to do this multi-site center study. We're also trying to get the word out nationally and truly appreciating that we are here today to present this to all of you. So, stroke survivors, they're not trying to game the system like I mentioned earlier. This particular presentation is interesting because we go from not only the idea and in the lab and how is it changing on a molecular level, but we also take it to the clinical research. This was implemented in a real world outpatient ambulatory clinic. It's possible, it's feasible. And we know that the recommendations have been there. Dr. Billinger, she started off by saying, this has been, what, 2014 was when that was published and you gathered data for years prior to that. So, what is it that we need to do to make that leap to make it actually happen? And plugging into a program similar to our cardiac rehab program, we know is safe, we know is effective. Now we just need to do that last piece of advocacy and having payers pay for it so that we can overcome some of those other hurdles. So, thank you for your time. We'll take any questions. Thank you. I'm Brenda Waller, Lynchburg, Virginia, private practice. I do see. than once they're discharged. So I heard you say that not all of your stroke patients were able to participate. What's the barrier there? Is it financial? Is it Medicare? Is it family support? So as you know, there's multiple barriers that are definitely there. The people that opted not to participate in the program, they went home and for whatever reason, they decided not to come back. It was a big investment for them to come back three times per week, multiple different sessions. As part of the research, we paid for the extra additional therapy, so that wasn't a barrier. We also partnered with Lyft and Uber in our area, so that overcame some of that transportation barrier. But it did require additional support from a family member, a caregiver, to help them get back and forth. In taking a look at the particular program, though, we wanted to make sure that we had something that was plug and play, as easy as possible for them. And so as opposed to creating a whole separate network specific for neurorehab, cardiac rehab already does that. So they help them with the medication management. They help communication back and forth with the physician. So plugging into a program that's already there is a little bit easier than trying to build one from the ground up. Okay. So what you're saying is that on a community level, when you don't have a lot of resources, if you could connect with your cardiac rehab program already and modify a few of the things that they do, and hopefully the patients would be willing to participate, then you could? Well currently it's not funded. We need to produce this data, because that's what the battle is. We need to get this data published, and for Medicare to look at it like it has already for cardiac patients, patients with chronic heart failure, patients with peripheral vascular disease, right now there's no funding for stroke patients to receive cardiac rehab. And this is why we're on this journey to try to produce the research out of Dr. Linder and Billiger's labs, the research out of what we're doing with this multi-site center study. Medicare told us, we won't fund this until you have data to prove that it really makes stroke patients better. So right now there's data to prove for cardiac patients. There's data to prove for patients with chronic heart failure and peripheral vascular disease. So they're all funded. And actually what the cardiologists told us at the Cardiovascular Institute at Rutgers that we did this with, they're like, PM&R docs, got to get on board. You got to get this data out there, because nobody's advocating for the stroke patients. They should already have this already funded, and this should be offered. And what Dr. Fleming was just saying, we're doing it because chronic heart failure and PVD is actually being done in cardiac rehab centers. So we're trying to make it very easily implementable by working in cardiac rehab centers and modifying the program so our stroke patients can go in there with this modified program. And everything's set up, and the nurses are trained with these patients on telemetry to know when it's safe and okay for them to continue and progress through this program. Thank you. Well, we first get cardiac clearance because some patients, as we said, have underlying cardiac disease. And then we basically, when we did the first study, we encouraged both groups to do a general walking program at home and general exercise in addition to their neural rehab, which is recommended. You know, Dr. Billinger and Dr. Linda went through the existing recommendations for stroke patients in general to remain active. So it's, again, a whole lifestyle change. It doesn't end after the three to four months of cardiac rehab, which is really phase, as we know, phase three of cardiac rehab to make it a lifelong journey. So that's what we're trying to do is lifestyle modification for our stroke patients. And as you know, post-stroke rehab is customized. It's individualized. People are going to need different things at different points of their recovery process. Part of them coming back to see the rehab physiatrist is so that we can make those modifications. So if spasticity emerged, we can do that. If neuropathic pain became an issue, we could handle that. So all of that was customized on an individual level at the physiatry appointment. Thank you. Yep. Hello, I'll make it quick. My name is Scott. I'm a third year medical student. Yeah, so my question was on where the 22% difference in readmission rates was coming from between those who received the intervention? So, yes, so we use the MIDUS data registry from the Cardiovascular Institute, which basically gathers data from stroke and cardiac patients throughout the state of New Jersey. So all of the patients that are tracked that have strokes within our healthcare system. So what ended up happening, it's all cause mortality. It's all cause readmission rate. So whether they were in for a UTI, a pneumonia, whatever they were in for, that's what we saw, a reduction in the people that did the program and went through the 12 weeks of the cardiac rehab program, and basically, hopefully, continued that same lifestyle modification to those that did not do the program. We saw a reduction in that all cause readmission rate. It's just kind of amazing that it wasn't from MI, heart failure, or stroke readmission. Yes, it would have been any of those, all types of admission, all cause readmission. It could have been another stroke. It could have been an MI. So anything that would cause a patient to go back into the hospital. So again, it's all cause readmission. Okay, thank you. Okay, sure. Thank you. Thank you, everyone.

aerobic exercise

stroke rehabilitation

neuroplasticity

exercise barriers

high-intensity interval training

walking outcomes

cardiac rehabilitation

stroke survivors

functional outcomes

Medicare coverage

policy changes