MORNING EVERYBODY, WHICH CAMERA?
THIS CAMERA.
THANK YOU FOR JOINING.
WE ARE DAY 2 OF THE NATIONAL
ADVISORY BOARD FOR MEDICAL
REHABILITATION RESEARCH AT NIERK
CHD.
IME TERESA CRUZ, I'M THE
DIRECTOR, I WANT TO THANK YOU
FOR JOINING US TODAY.
WE HAD AN INCREDIBLE DAY
YESTERDAY, I THINK AND IF YOU
MISSED ANY OF IT, IT'LL BE ON
THE NIH VIDEOCAST AND I WOULD
ENCOURAGE YOU TO GO BACK AND
TAKE A LOOK PARTICULARLY IN THE
AFTERNOON.
YOU CAN SKIP ALL THE
BUREAUCRATIC STUFF IN THE
MORNING BUT THE AFTERNOON
SESSIONS WERE REALLY JUST
INCREDIBLE, POWERFUL DISCUSSIONS
OF THE LIVED EXPERIENCE AND THE
NEED FOR INCLUSION OF PEOPLE
WITH DISABILITIES IN THE EFFORTS
THAT WE SUPPORT.
TODAY WE WILL SHIFT THE TONE A
LITTLE BIT AND DIG INTO SOME
MORE SCIENCE.
SO WE HAVE 4 GREAT SPEAKERS
LINED UP.
AND I DON'T WANT TO TAKE AWAY
BARBARA SUNNEDDER WITH THE
INTRODUCTIONS BUT WE AGAIN,
BEFORE WE WRAP AROUND NOON
TODAY, WE ARE GOING TO ASK FOR
TOPICS FOR OUR MAY MEETING.
SO KEEP IN MIND AS YOU'RE
LISTENING TO THESE TALKS OR
OTHER THINGS THAT WOULD BE
HELPFUL TO YOU ALL TO HEAR WHEN
WE MEET AGAIN IT MAY.
NAND CAN I ALSO ADD THAT IT'S
NOT JUST THIS LITTLE WINDOW BUT
IT'S DURING THE COURSE OF YOUR
CAREERS, DURING THE OTHER
MONTHS, FEEL FREE TO KEEP
ENGAGING US ON TOPICS YOU WANT
TO BRING TO THE BOARD.
SO ANYWAY ISSUES IT'S MY
PLEASURE TO INTRODUCE 1 OF OUR
FELLOW BOARD MEMBERS
DR. FLORA HAM OND IS A BOARD
CERTIFIED PHYSICIAN MEDICINE AND
REHAB PATHWAY GIVES SESSION AND
PROFESSOR AND CHAIR OF PHYSICAL
MEDICINE AND REHABILITATION AT
INDIANA UNIVERSITY SCHOOL OF
MEDICINE EMPLOY SHE'S A PROJECT
DIRECTOR AT THE INDIANA
TRAUMATIC BRAIN INJURY MODEL
SYSTEMS AND MODEL ITS' COMMITTEE
A PROMINENT RESEARCHER IN THE
FIELD OF TBI AND WE WILL LIKE TO
HAVE HER SHARE HER PASSIONS AND
SCIENTIFIC BACKGROUND WITH US AT
THIS MEETING.
SO FLORA, WE TURN IT OVER TO
YOU.
>> THANK YOU.
GREAT.
THANK YOU.
FIRST RALPH ASKED ME FOR A TITLE
AND I HAD A VISION OF WEAVING
TOGETHER ALL THE THINGS I
LEARNED SO FAR IN MY CAREER AND
THEN COULDN'T REALLY FIGURE OUT
HOW TO CREATIVELY WEAVE THAT SO
I DECIDED TO FOCUS ON SOMETHING
THAT REALLY TAKE WHAT IS WE HAVE
FOUND TO CREATE A MOVEMENT IN
CHANGING OUTCOMES FOR PEOPLE
WITH BRAIN INJURY SO THAT'S WHAT
I WILL TALK TO YOU ABOUT TODAY.
SO AS AN OVERVIEW OF WHAT I WILL
COVER, FIRST I'M GOING TO GO
OVER A CHANGE IN THINKING ABOUT
BRAIN INJURY AS A CHRONIC COP
DITION AND THE DATA THAT LAID
THAT OUT FOR US OR AT LEAST A
GLIMPSE OF THAT AND THAT IT'S
ACTUALLY REALLY A DYNAMIC
CONDITION, NOT JUST CHRONIC.
AND THEN TALK TO YOU BRIEFLY
ABOUT HOW OTHER CONDITIONS HAVE
MANAGED TO USE A CHRONIC DISEASE
MODELS TO IMPROVE OUTCOMES, AND
THEN LASTLY AN EFFORT UNDER FOOT
TO IMRIEWF THE MODEL OF CARE FOR
BRAIN INJURY.
SO FIRST FOCUSING ON BRAIN
INJURY AS A CHRONIC CONDITION
EMPLOY WE STARTED THINKING ABOUT
THIS BACK 2009, THE IOM REPORT
WAS INSTRUMENTAL IN LAYING OUT
THE EVIDENCE THAT REALLY AS
CLINICIANS WE'VE KNOWN FOR A
LONG TIME BUT LAYING OUT THE
EVIDENT THAT THERE REALLY IS
SUFFICIENT EVIDENT THAT THERE
ARE LONG-TERM ISSUES POST TBI,
SOUNDS PRETTY SIMPLE BUT WE
REALLY NEEDED THAT EVIDENT
CONSOLIDATED TO TELL THE STORY.
AND THEN NEXT, DR. MAZAOU, AND
DR. DEWIT POSITED THAT BRAIN
INJURY WAS REALLY A DISEASE AND
NOT AN EVENT AND POINTED THAT
THAT MANY CARING FOR BRAIN
INJURY AND THE MODEL AT THE TIME
WAS A LOT OF THAT RECESSITATION
AND THEN REALLY FORGETTING
PEOPLE AND THINKING THAT EITHER
THERE WEREN'T LONG-TERM ISSUES
OR IF THERE WERE, THERE WAS
NOTHING TO BE DONE ABOUT IT.
AND THEN DR. CORRIGAN AND I WITH
THE EFFORTS FROM GALVESTON BRAIN
INJURY CONFERENCE PUBLISHED A
PAPER THAT SAID WE CAN DO
BETTER.
BRAIN YOUR IS A CHRONIC AND
DYNAMIC CONDITION AND THAT BEING
PROACTIVE AND WITH SURVEILLANCE
THAT WE CAN DO A BETTER JOB AND
WE NEED TO FIGURE THAT OUT.
IT WAS A CALL TO ACTION AND SO
THAT WAS BACK IN 2013, WE NOW
ARE CONSIDERING REVISITING THAT
AND GIVING AN UPDATE TO WHERE WE
ARE BECAUSE CERTAINLY WE KNOW
MORE NOW ABOUT HOW WOE CAN HAVE
AN EFFECTIVE CALL TO ACTION
EMPLOY SO THE--IN THAT 2013
ARTICLE WE PRESENTED THE
FOLLOWING DATA JUST TO TELL THE
PICTURE, I JUST UPDATED THIS
SLIDE SO NOW IT GOES FURTHER OUT
POST INJURY BUT IT'S THE
SAMEULAR FINDINGS FOR BACK TO
2013.
SO BASICALLY, THE TBI MODEL
SYSTEM SYSTEM DATA WHERE WE HAVE
FOLLOWED PEOPLE OUT TO AT LEAST
30 YEARS POST INJURY.
THIS SLIDE USES THE GLASGOW
OUTCOME SCALE EXTENDED.
WHAT WE DID IS WE LOOKED AT DID
PEOPLE CHANGE IN THEIR DPLAS GOW
OUTCOME SCALE FROM 1 TIME TO THE
NEXT AND BY HOW MUCH AND WHAT
YOU WILL SEE HERE IS THE VERY
FIRST COLUMN.
YOU SEE THAT'S A COMPARISON OF
HOW PEOPLE WERE ON THEIR GOSE
FROM YEAR 1 TO YEAR 2.
THE NEXT COLUMN IS A COMPARISON
OF YEAR 2 TO 5, 5 TO 10, 15-20,
20-25, AND 25-30 AND YOU CAN SEE
THE SAMPLE HAS DECREASED
OVERTIME AS WE HAVE MANY MORE
THAT WE'RE FOLLOWING IN THE
DATABASE THAT WERE EARLIER FROM
POST INJURY.
THE COLOR IS BLUE MEANS THEY DID
NOT CHANGE FROM 1 EPIC TO THE
NEXT IN REGARDS TO THEIR GSE
SCORE.
THE PEOPLE WHO DIDN'T CHANGE AT
ALL, THAT'S ABOUT 41-49%
DEPENDING ON WHICH EPIC, SO MORE
PEOPLE ARE CHANGING THAN ARE NOT
CHANGING.
THE GREEN, MEANS THEY IMPROVED.
SO DETENDING--DEPENDING ON THE
CONDITIONS.
SO A CONDITION WHERE WE USED TO
THINK WELL, YOU GOT WAYOU GOT
AND YOU WILL NONAPOPTOTIC THE
HAVE ANY CHANGE.
THESE ARE PEOPLE THAT ARE
IMPROVING AND IN FACT, THEY ARE
IMPROVING WITH THAT ATTITUDE
EMPLOY YOU WILL SEE EVEN THE
PEOPLE YEARS POST INJURY ARE
CONTINUING TO IMPROVE.
THE OTHER SIDE OF THAT, WE OFTEN
WORRY ABOUT DECLINE OVER TIME,
THE RED PINK COLOR IS DECLINED
AND YOU WILL SEE THE 23-37%
DECLINED EITHER 1 OR MORE
POINTS.
SO THIS SLIDE DOES INCLUDE
DEATHS.
THE DATA LOOKS SIMILAR IF YOU
WERE TO TAKE OUT DEATHS.
CERTAINLY THESE ARE ALL
DIFFERENT CAUSES, IT MAY NOT BE
RELATED TO THEIR BRAIN YOUR OR
IT MAY BE.
SO I MENTIONED THE GALVESTON
BRAIN INJURY CONFERENCE, THE
GALVESTON BRAIN INJURY
CONFERENCE IS A THINK TANK THAT
CONVENES ABOUT 40 PEOPLE,
EXPERTS IN THE FIELD AND HAS
TACKLED DIFFICULT ISSUES IF I
REMEMBER CORRECTLY IT STARTED
AROUND 2000 AND FROM 2011-2014
WE CONVENED ON THE TOPIC OF
BRAIN INJURIES OR CHRONIC
CONDITION AND WHAT CAN WE DO
ABOUT IT.
2011 WAS JUST GETTING OUR HEAD
AROUND THE CONCEPT AND ALL
GETTING ON THE SAME PAGE,
TALKING ABOUT COULD THIS BE A
NEGATIVE THING SOME SIGMA, ET
CETERA, AND THEN CONVENING IN
2012, WE CAME UP WITH A
STRATEGIC PLAN.
WE CREATED A DEFINITION TR
CHRONIC BRAIN INJURY EMPLOY THE
DEFINITION WE CREATED AT THAT
TIME WAS INJURY TO THE BANE CAN
EVOLVE INTEREST A LIFE LONG
HEALTH CONDITION, TERMED CHRONIC
BRAIN INJURY.
CHRONIC BRAIN INJURY IMPAIRS THE
BRAIN AND OTHER ORGAN SYSTEMS
AND MAY PERSIST OR PROGRESS OVER
AN INDIVIDUAL'S LIFE SPAN.
AND THE OTHER THING WE DID THAT
YEAR IS WE CREATED A VISION
WHICH HAS THEN MOVED US FORWARD
FROM THERE, BRAIN INJURY SHOULD
BE IDENTIFIED AND PROACTIVELY
MANAGED AS A LIFE LONG DISEASE
WHICH WILL RESULT IN
IMPROVEMENTS IN LONGEVITY,
LEVELS OF DISABILITY, EVENTS IN
SOCIETY AND QUALITY OF LIFE.
SO THAT'S QUITE A VISION AND
WHAT WE'RE REALIZING IS REALLY
THE BRIDGE, REALLY WE'VE GOT THE
INITIAL PART OF THE BRIDGE
BUILT, EXCELLENT ACUTE CARE, AND
THEN REALLY WE NEED SOME
INFRASTRUCTURE BUILT TO TAKE
CARE OF THE REST SO WE CAN
ACHIEVE OPTIMAL LIVING AFTER
BRAIN INJURY.
SO THE TYPICAL PATH POST TBI,
VARIABLE AND LIMITED ACCESS TO
SPECIALIZED PROGRAMS.
WE HAVE LIMITED PROVIDERS,
EXPERTS IN BRAIN INJURY, ARE
HARD TO FIND AND NOT ENOUGH, SO
THE CARE THAT 1 GETS IS VERY--IT
VARIES FROM 1 PLACE TO THE NEXT
EVEN WITHIN A STATE.
THE CARE YOU GET IS REACTIVE AND
VERY AIMED AT SIGNS AND
SYMPTOMS, LESS PROACTIVE.
THE FOLLOW UP 1 GET SYSTEM
BRIEF, REACTIVE, INFREQUENT,
IT'S OFTEN PATIENT-INITIATED AND
IT'S VERY COMMON FOR PEOPLE TO
BE DROPPED FROM A BRAIN INJURY
CLINIC.
YOU KNOW YOU'RE DOING FINE NOW,
WE NEED NEED TO SEE YOU ANYMORE.
SO USUALLY WITHIN THE FIRST
COUPLE YEARS YOU CAN BE DROPPED
FOR FOLLOW UP AS A LACK OF
VISION OF WHAT COULD HAPPEN.
AND THE INTENSITY OF SERVICE IS
GENERALLY LOW, A LOT OF SERVICES
EARLY ON AND THEN THE THOUGHT
THAT YOU'VE STABILIZED AND A
LACK OF ATTENTION TO SERVICES
LATER POST INJURY.
THE DIDACTIC, THE EDUCATION IS
VERY BRIEF.
LIMITED TO NO ACCORD NATION OF
THE CARE, LIMITED NAVIGATION OF
SERVICES AND COMMUNICATION AND
LIMITED CASE MANAGE AM
AVAILABILITY, THERE IS SOMETHING
CALLED RESOURCE FACILITATION
THAT HAS BEEN GAINING STEAM OVER
THE PAST DECADE, LIMITED
ATTENTION, AND SOLUTIONS TO
CHALLENGES IN SOCIAL
DETERMINANTS OF HEALTH AND
COMMUNITY BARRIERS AS WELL AS
MEDICAL BARRIERS AND VERY LITTLE
ATTENTION TO WHAT CAN BE DONE
FOR CAREGIVERS.
SO, WITH ALL THAT IN MIND, WE
WERE THINKING WELL, WHAT HAVE
OTHER CONDITIONS DONE TO ADDRESS
THIS, CERTAINLY WE KNOW THAT
CHRONIC CONDITIONS USE MORE
HEALTHCARE SERVICES AND WITH
THAT AS A HUGE COST AND SO OVER
THE PAST COUPLE DECADES
HEALTHCARE PLANS HAVE DESIGNED
CHRONIC DISEASE MANAGEMENT
APPROACHES TO IMPROVE THE CARE
AND REDUCE THE COST AND
DECREASED RESOURCE UTILIZATION.
SO EXCELLENT EXAMPLES ARE WHAT'S
BEEN DONE FOR DIABETES, COPD,
ASTHMA, CONGESTIVE HEART
FAILURE, RENAL DISEASE, YOU CAN
PROBABLY--THINGS HAVE COME TO
YOUR MIND OF WHAT'S BEEN DONE
OVER THE PAST COUPLE DECADES.
FOR EXAMPLE WITH CONGESTIVE
HEART FAILURE THERE'S A WHOLE
PROTOCOL OF WHAT CAN BE DONE TO
TRY TO KEEP PEOPLE FROM
NEEDING--GOING INTO AN
EXACERBATION AND NEEDING TO END
UP IN THE HOSPITAL.
SO, WAYS THEY'VE DONE THAT,
THERE HAVE BEEN A LOT OF
DIFFERENT APPROACHES,
COLLABORATIVE CARE MODEL IS 1,
THE WAGNER INTEGRATED CARE MODEL
OR THE CHRONIC CARE MODEL IS
ANOTHER.
I'M GOING TO FOCUS ON TALKING A
LITTLE BIT ABOUT THE WAGNER
MODEL.
SO HERE IS A DEPICTION OF THE
WAGNER MODEL, HE LAID OUT THAT
THERE'S THE HEALTH SYSTEMS AND
THE COMMUNITY.
AND WITHIN THE HELT SYSTEMS
THERE'S THE DELIVERY SYSTEM,
DECISION SUPPORT ISSUES
SELF-MANAGEMENT AND CLINICAL
INFORMATION SYSTEMS, WHERE IN
THE COMMUNITY, IT'S PUBLIC
POLICY AND RESOURCES, AND
SUPPORTIVE ENVIRONMENT.
SO WHAT DOES ALL THAT MEAN ?
DELIVERY SYSTEM, AT RISK CASE
MANAGEMENT, SO CASE MANAGEMENT
FOR THOSE WHO ARE AT GREATEST
NEED, BEING ABLE TO IDENTIFY
WHAT THAT NEED IS AND HAVING A
PLAN IN PLACE TO ADDRESS
THOSENY
NEEDS AND EDUCATED ACTIVATED
CLINICAL TEAMS, DECISION SUPPORT
IS GUIDE LINES, SEMINARS, TO
HELP HAVE THE TEAM AT THE TOP OF
THEIR KNOWLEDGE BASE CAPACITY
BUILDING, AND WORKING HAND IN
HAND WITH CONSULTANTS WITH THAT
EXTRA EXPERTISE.
CLINICAL INFORMATION SYSTEMS
INCLUDE THINGS LIKE REGISTRIES,
AND PERFORMANCE METRICS,
SUPPORTED SELF-MANAGEMENT.
AND I'M GOING TO GO INTO THAT A
LITTLE BIT IN THE NEXT SLIDE.
IT'S A VERY IMPORTANT KEY
FEATURE TO THE CHRONIC CARE
MODEL AND SUPPORTIVE ENVIRONMENT
AND PUBLIC POLICY RESOURCES.
SO OFFENSE TIMES PIECES OF THE
CHRONIC CARE MODEL ARE
IMPLEMENTED RATHER THAN THE
ENTIRE CHRONIC CARE MODEL.
THIS SYSTEMATIC REVIEW I THOUGHT
WAS HELPFUL IN SHOWING HOW OFTEN
THE DIFFERENT PIECES ARE
IMPLEMENTED AND YOU SEE HERE
THAT MOST OFTEN IT'S
SELF-MANAGEMENT THAT IS
IMPLEMENTED.
IN THIS STUDY, THEY FOUND 46% OF
THE STUDIES USED SELF-MANAGEMENT
AND NEXT WAS DELIVERY SYSTEM
DESIGNS FOLLOWED BY DECISION
SUPPORT, AND CLINICAL
INFORMATION SYSTEMS AND WHAT YOU
SEE HERE IS ALMOST NEVER A USE
OF COMMUNITY RESOURCES.
SO SELF-MANAGEMENT IS THE COMMON
KEY ELMETROPOLITAN OF THIS MODEL
AND VERY IMPORTANT FOR HELPING
PEOPLE LIVE WITH THEIR INJURY OR
ILLNESS.
MOST PEOPLE SPEND VERY LITTLE
TIME IN FRONT OF A HELT CARE
PROVIDER SO YOU CAN SEE HOW
SELF-MANAGEMENT BECOMES REALLY
IMPORTANT TO MANAGING AND NOT
BEING DEPENDENT ON THE MEDICAL
SYSTEM.
SO SELF-MANAGEMENT, AND THE GOAL
IS TO IMPROVE SELF-EFFICACY
THROUGH GOAL ATTAINMENT BY
PERSUASION, PHYSICAL ACTIVITY
LINKED TO PHYSICAL AS WELL AS
CERTAINLY--CERTAINLY MOTIONAL
STATUS.
FOR EXAMPLE, DIABETES AND BLOOD
SUGAR AND BEING ABLE TO
RECOGNIZE WHEN YOU'VE GOT A
MARKER, THE BLOOD SUGAR IS HIGH
AND WHAT TO DO AND HOW TO MANAGE
THAT IT REQUIRES THAT THE PERSON
WITH THE INJURY OR ILLNESS
RECOGNIZE THE ISSUE AND THEN
ALSO, INVOLVES ABILITY TO HAVE
GOAL SETTING, HAVE SUPPORT TO
HELP IN ADJUSTING THOSE GOALS
AND SELF-MONITORING.
IT'S TOUTED THAT THERE ARE 6
CORE SKILLS, PROBLEM SOLVING
SKILLS, SELF-TAYLORRING AND YOU
THINK ABOUT APPLYING THIS TO
BRAIN INJURY, YOU REALIZE THERE
ARE OTHER SKILLS THAT COME TO
MIND FOR EXAMPLE, SELF-AWARENESS
AND INITIATION.
IN THINKING ABOUT THE NEEDS OF
APPLYING SELF-MANAGEMENT TO
PEOPLE WITH BRAIN INJURY, THERE
ARE MODELS OUT THERE THAT
ADDRESS ISSUES THAT PEOPLE WITH
BREAN INJURY MAY HAVE, PEOPLE
WITH BRAIN INJURY MAY OFTEN HAVE
ISSUES WITH SUBSTANCE AND
ALCOHOL USE, DIABETES, CHRONIC
ILLNESS AND GENERAL, DEPRESSION,
PAIN.
THERE ARE ALREADY QUITE A BIT OF
WORK ON THOSE SYMPTOMS AND
ILLNESSES THAT WE CAN TAP INTO
AND LEARN FROM.
WE ARE IN THE PROCESS OF TRYING
TO LEARN HOW MUCH THAT MID NEED
TO BE MODIFIED TO HELP PEOPLE
WITH BRAIN INJURY.
THE OTHER IMPORTANT PIECE OF A
CHRONIC DISEASE MODEL IS TO
FIGURE OUT WHO NEEDS WHAT SO
THAT YOU CAN FIGURE--YOU'RE
GETTING THE RIGHT SERVICES TO
THE RIGHT PEOPLE, SPENDING THE
RIGHT RESOURCES.
AND SO, THIS IS A DIAGRAM THAT
SHOWS, AND MOST CHRONIC DISEASES
THAT 70-80% ARE AT LOW RISK AND
THOSE AT LOW RISK WOULD MORE
THAN LIKELY NEED SUPPORTED
SELF-MANAGEMENT APPROACH WITH A
SMALL SLIVER PERCENTAGE NEEDING
MORE PROFESSIONAL MANAGEMENT.
AND AT THE NEXT LEVEL UP IS THAT
THE MODERATE RISK WOULD NEED
MORE OF A DISEASE MANAGEMENT
APPROACH AND THEN FINALLY, THOSE
AT HIGHEST NEED, THE MOST
COMPLEX, WOULD REQUIRE CASE
MANAGEMENT.
SO REALLY WHEN WE'RE TALKING
ABOUT THIS MODEL, WE'RE NOT
TALKING ABOUT ALL UNDER THE
RESOURCES OF EVERYONE, WE'RE
TRYING TO FIGURE OUT WHO NEEDS
WHAT.
SO TO FOCUS NOW ON WHAT ARE WE
DOING FOR TRYING TO IMPROVE CARE
FOR THE LIFE LONG LIVING WITH
BRAIN INJURY.
WE ARE FORTUNATE IN 2020 TO
RECEIVE FUNDING FOR NIDLR, TO
CREATE A MODEL FOR PEOPLE WITH
BRAIN INJURY TO LIVE WITH, LIVE
WITH BRAIN INJURY.
SO THE OVERALL GOAL OF THE GRANT
WAS TO DEVELOP A CHRONIC DISEASE
MODEL FOR BRAIN YOUR WITH
DIVISION OF CREATING ACCESSIBLE
AND INTEGRATED CONFIDENT AND
PATIENT HAVED CHRONIC DISEASE
MANAGEMENT FOR AN INDIVIDUAL
WITH PERSISTING EFFECTS OF BRAIN
INJURY.
AND TO THE RIGHT, YOU SIMPLY SEE
KIND OF THE STRUCTURE OF THE
GRANT IS THAT FOR THE FIRST 12
MONTHS WE REVIEWED THE
LITERATURE AND TRIED TO LEARN
FROM OTHER DISEASE PROCESSES IN
REGARDS TO THE STRUCTURE, THE
DIFFERENT CLINICAL ISSUES, AND
REGARDS TO SELF-MANAGEMENT IN
THIS AREA.
SO WITHIN THE NEXT 18 MONTHS,
TRYING TO REFINE THE MODEL THAT
WE HAD ORIGINALLY PROPOSED AND
THEN IN THIS LADDER PHASE, NOW,
WE ARE CONDUCTING FEASIBILITY
PROJECTS TO TEST OUT DIFFERENT
PROJECTS, DIFFERENT ASPECTS OF
THE MODEL AND THEN FROM THERE
INTEGRATING THOSE FINDINGS INTO
A FINAL MODEL.
SO THIS IS WHAT WE'VE PROPOSED
FOR OUR MODEL, SO 1 WE DECIDED
THAT WE WOULD TART WITH A
CHRONIC CARE MODEL THAT I SHOWED
YOU EARLIER.
AND THEN, IN TALKING WITH
PEOPLE, WITH THE INJURY, IN
PARTICULAR, AS WELL AS
PROVIDERS, WE FELT LIKE IT'S
VERY IMPORTANT TO ADD A PATIENT
CENTERED APPROACH AND THAT IT
NEEDED TO BE A MULTIDISCIPLINARY
PROGRAM STRUCTURE AND INSTEAD OF
CALLING IT A DELIVERY SYSTEM OR
A CLINIC, WE DECIDED
MULTIDISCIPLINARY PROGRAM
THAT--I SAID MULTIDISCIPLINARY
THAT THERE'S A LOT OF DIFFERENT
EXPERTISE THAT WILL NEED TO BE
AT THE TABLE.
WE DECIDED TO FOCUS ON THE
EXPERTISE RATHER THAN THERE ARE
THE TYPES OF NEEDS RATHER THAN
LABELS, SO, WE DECIDED BRAIN
INJURY MEDICINE SPECIALISTS ARE
AN IMPORTANT PIECE OF THIS AS
ARE PEOPLE WHO HAVE EXPERTISE IN
AFFECT BEHAVIOR AND COGNITION.
THIS WOULD INCLUDE THE ABILITY
TO ADAPT AND SUPPORT
SELF-MANAGEMENT, EXPERTISE IN
MOVEMENT AND EXERCISE, EXPERTISE
WITH SOCIAL AND VOCATIONAL
ENGAGEMENT AND COMMUNITY
RESOURCE NAVIGATION.
ALL OF THAT CREATING OUR
SUPPORTIVE ENVIRONMENT AND ALSO,
CARE COORDINATION.
SO I MENTIONED THE IMPORTANCE OF
RISK STRATIFICATION, SO THAT IS
A KEY PIECE THAT WE'LL NEED TO
FIGURE OUT, IS WHO NEEDS WHAT
AND WE DECIDED THAT AT LEFT AT
THIS POINT, WE THINK THAT THAT
INTENSITY, THAT RISK WOULD BE
BASED ON 3 COMPONENTS, MEDICAL
COMPLEXITY, INDEPENDENT AND
SELF-MANAGEMENT, SO 1'S ABILITY
TO SELF-MANAGE WHETHER IT'S
THEMSELVES OR WITH THE SUPPORT
OF OTHERS, HELPING THEM AND
LASTLY, THEIR COMMUNITY
RESOURCES INCLUDING AN EMPHASIS
ON THEIR SOCIAL DETERMINANTS OF
HEALTH.
AND THEN OF COURSE, PROBABLY THE
HARDEST THING TO TACKLE IS
FUNDING AND TRYING TO FIGURE OUT
HOW THIS WILL BE FUNDED AND
REALIZING THAT FEE FOR SERVICE
ITSELF WILL NOT LIKELY DO THIS
AND SO TIME TO EXPLORE DIFFERENT
WAYS OF FUNDING.
SO ALL OF THIS PUT TOGETHER, OUR
VISION IS HAVE AN OPTIMALLY
INFORMED AND ACTIVATED
PARTICIPANT.
OPTIMALLY INFORMED AND ACTIVE
PARTIC PAINT SERVED BY A PRO
ACTIVE TEAM.
SO OUR CORE PRINCIPALS, PREPARE
PROACTIVE PROVIDERS, INFORMED
AND ACTIVATED AND SUPPORTIVE
PEOPLE WITH TBI AND THEIR
CAREGIVERS, ACTIVE COMMUNITIES
AND PREPARE PROACTIVE COMMUNITY
PARTNERS AND A PERSON CENTERED
IN CULTURALLY HUMBLE APPROACH.
THIS PIECE ABOUT THE COMMUNITY
IS A REAL OPPORTUNITY FOR PEOPLE
WITH BRAIN INJURY THAT IS REALLY
DIFFERENT THAN A LOT OF THE
CHRONIC CARE MODELS BEFORE US.
SO WE'VE COME UP WITH 9
PRINCIPLES AND COMPONENTS,
EDUCATION AND SUPPORT,
IDENTIFYING AND TREATING
HAZARDS, REMOVING HAZARDS ISSUES
REDUCING POTENTIAL ANDROGEN
ROUGH ATOMIENIC HARM,
PRESCRIBING APPROPRIATE
TREATMENTS, FACILITATING SOCIAL
AND INTELLECTUAL ENGAGEMENT,
ENCOURAGING HEALTHY BEHAVIORS,
REVIEW OF COMORBID CONDITION
ANDS MEDICATIONS, FACILITATING
COMMUNICATION AND EVALUATING
COMMUNITY BARRIERS AND
OPPORTUNITIES.
THE THOUGHT OF THIS WAS TAKING
THE CHRONIC CARE MODEL WITH
ADDING IN COLLABORATIVE
APPROACHES AND THEN ADDING IN
WHAT WE KNOW ABOUT BRAIN HEALTH.
AND THERE'S A MOVEMENT IN
MEDICINE AT THIS TIME, THE LIFE
TILE MEDICINE WHICH MAPS ON TO
BRAIN HEALTH AND SO CERTAINLY
THOSE 6 PILLARS OF LIFESTYLE
MEDICINE APPLY AND HAVE BEEN
INTEGRATED INTO THIS MODEL.
THOSE 6 PILLARS, NUTRITION,
EXERCISE, SLEEP, STRESS MANAGE
AM, RISKY SUBSTANCES AND
RELATIONSHIPS, SO CAN YOU SEE
HOW WE ARE INTEGRATING THAT.
SO THE NEXT 9 SLIDES I WILL JUST
TOUCH ON WHAT THESE 9 COMPONENTS
INCLUDE.
SO EDUCATION AND SUPPORT OF THE
PARTICIPANT AND THEIR CAREGIVER,
THERE'S A LOT THAT'S PACKED INTO
THIS 1 COMPONENT, CERTAINLY ALL
THE DIFFERENT REFERRALS THAT
SOMEBODY NEEDS, INCLUDING
RESOURCES, THERAPY SERVICES,
SPESHIST, VERY IMPORTANT TO BE
CONNECTED TO SUPPORT GROUPS,
EDUCATION AND HAVING EDUCATIONAL
MATERIALS THAT MAP ON TO THE
DIFFERENT ASPECTS OF LIVING WITH
BRAIN INJURY, AND HELPING PEOPLE
HAVE THE EDUCATION THEY NEED TO
OPTIMIZE THEIR OUTCOMES.
AND ATTENTION TO THE CAREGIVER
AND BEING ABLE TO MONITOR AND
SUPPORT THE CAREGIVER IN THEIR
EMOTIONAL AND PHYSICAL HEALTH,
INFORMAL TELEPHONE SUPPORT AND
THEN IN THIS COMPONENT IS WHERE
WE WILL DIG INTO MAKING SURE
THAT SELF-MANAGEMENT IS AN
OPTION INN CLUING TRAINING FOR
SELF-MANAGEMENT, A MANUEL
CONSIDERING IF PEOPLE NEED
COMPENSATORY STRATEGIES IN ABLE
TO BE ABLE TO DO SELF-MANAGEMENT
AND SKILLS EMPOWERMENT IN
ORDER
TO DO SELF-MANAGE AM.
THE SECOND IS TO IDENTIFY
POTENTIAL HARMS AND REMOVING
THOSE ARMS.
SO XCHS ARE HELPING WITH STRESS
MANAGE AM, DEPRESSION, ANXIETY,
IRRITABILITY, ANGER, AGGRESSION,
SOME OF THE HAZARDS THAT SOMEONE
IS DEALING WITH AFTER BRAIN
INJURY, CERTAINLY SUBSTANCE USE
CAN BE AN ISSUE AN BRAIN INJURY,
AND SO IS REDUCING THE NEED TO
REDUCE FALL RISK.
THE OTHER THING WE TALK ABOUT IS
THAT WE'RE NOT CAUSING HARM.
SO A REVIEW OF MEDICATIONS AND
TREATMENTS TO TRY TO MINIMIZE
IATROJENNIC HARM THROUGH
MEDICATIONS.
AND THEN 1 OF OUR STAKEHOLDERS
POINTED OUT WE WANT TO AVOID
HARM THROUGH GIVING
MISINFORMATION, RIGHT?
THROUGH HAVING POOR EXPECTATIONS
OF WHAT COULD HAPPEN AND SO
WE'RE MEN MYSELFING THE OUTCOME
BECAUSE WE HAVE LOW
EXPECTATIONS.
SO AVOIDING UNSUBSTANTIATED
PESESIMISM ABOUT FUTURE
OUTCOMES, WHILE ALSO HAVING
REALISTIC AND APPROPRIATE
INFORMATION.
IT'S A FINE BALANCE.
PREKRIEBING TBI APPROPRIATE
TREATMENTS TO AUGMENT FUNCTION
AND RECOVERY, THAT SOUNDS PRETTY
OBVIOUS BUT AS I POINTED OUT,
IT'S VERY COMMON TO ARE A LOT OF
SERVICES UP FRONT AND THEN HAVE
A LOW EXPECTATIONS ON WHAT'S
NEEDED LATER.
SO EANGZ TO PREKRIEBING
APPROPRIATE TREATMENTS THAT
ARENIED THROUGHOUT THE LIFE
SPAN.
THIS IS A VERY IMPORTANT ASPECT,
THIS IS WHERE WE'RE REALLY
STARTING TO PULL IN ASPECTS WE
KNOW ABOUT BRAIN HEALTH.
SO NUMBER 5 IS TO FACILITATE
SOCIAL AND INTELLECTUAL ENGAGE
AM.
SO THE MODEL HAS US REVIEW THE
EXTENT OF SOCIAL INTERACTIONS OF
THE PARTICIPANT AND THEN REVIEW
SOCIAL SUPPORTS AND THEN HELP
DEVELOP A PLAN TO ENGAGE IN
VALUED ACTIVITIES.
SO OFTEN TIMES WE DON'T HAVE A
SOLID PLAN IN PLACE WHEN SOMEONE
LEAVES OUR CLINIC.
ENCOURAGE HEALTHY BRAIN
BEHAVIORS, THIS INCLUDES ALL
SORTS OF DIFFERENT ASPECTS OF
HEALTHY LIVING, INCLUDING SLEEP,
TOBACCO USE, ALCOHOL, MARIJUANA,
PHYSICAL EXERCISE, NUTRITION,
PREVENTING REINJURY, WHICH IS A
REALLY IMPORTANT PART FOR PEOPLE
WITH BRAIN INJURY.
WE REALIZE THIS IS A HUGE TASK
AND CERTAINLY NOT ALL ADDRESSED
IN 1 CLINIC, THIS WOULD REQUIRE
FIRST OF ALL FINDING OUT WHERE
SOMEONE HAS AWARENESS AND DESIRE
AND HAS THE BEST OPPORTUNITY IN
LAYING OUT A PLAN TO GET ON THIS
ROAD TO IMPROVING BRAIN HEALTH
THROUGH THESE ACTIVITIES.
ALSO HOW DO WE MANAGE COMORBID
HEALTH CONDITIONS, SO FIRST OF
ALL IDENTIFYING AND SCREENING
FOR COMORBID HEALTH CONDITIONS
THAT WE KNOW ARE COMMON AND
OFTEN ASSOCIATE WIDE BRAIN
INJURY ASK THEN LAYING OUT,
FIGURING OUT HOW MUCH THEY'RE
IMPACTING THE PERSON WITH YOUR
AND LAYING OUT A PLAN OF HOW
THEY CAN BEST BE MANAGED.
SOME OF THE ISSUES OF COMORBID
CONDITIONS ARE BEST MANAGED BY
PRIMARY CARE BUT MAY NEED SOME
FACILITATION FROM A BRAIN INJURY
SPECIALIST SO THEY CAN PERHAPS
BE MORE SUCCESSFUL IN THEIR
MANAGEMENT, SO FOR EXAMPLE,
DIABETES, HYPERTENSION, HYPER
LIPIDEMIA, WOULD BE ABOUTEST IN
OUR OPINION, MANAGED BY THE
PRIMARY CARE PHYSICIAN, BUT THEY
MAY NOT HAVE A PRIMARY CARE
PHYSICIAN AND THEY MAY NEED HELP
FINDING 1 OR THEY MIGHT NEED
HELP IN ADDRESSING COGNITIVE
ISSUES SO THAT THEY CAN BE
COMPLIANT AND MORE SUCCESSFUL
WITH MANAGING THE PRESCRIBED
CARE.
OR SOME OF THESE MAY BE BEST
ADDRESSED BY REHABILITATION
PROFESSIONAL OR OTHER TYPE OF
PHYSICIAN FOR EXAMPLE,
NEUROENDOCRINE DISORDERS, AND
OTHER EXAMPLES.
FACILITATE COMMUNICATION,
BELIEVING YESTERDAY AND AS THE
DOCTORS POINTED OUT QUITE
CLEARLY THE CHALLENGES OF
COMMUNICATION FROM PROVIDER TO
PROVIEDMANNER WHICH CAN THEN
CREATE A MISSTEP IN SOMEONE'S
OUTCOME AND THEIR CARE AND ALSO
COMMUNICATION BETWEEN
PARTICIPANT AND PROVIDER IS SO
IMPORTANT EMPLOY EMPLOY AND
LASTLY OFFERING COMMUNITY
BARRIERS AND OPPORTUNITIES TO
IMPROVE OUTCOMES SO THAT'S
SCREENING FOR BASIC NEEDS
INCLUDING SOCIAL DETERMINANTS OF
HEALTH AND FACILITATING
CONNECTIONS TO TRY OUR BEST TO
RESOLVE THOSE ISSUES.
SO TO SUM IT UP, THE BE HEALTHY
PATH IS PERSON-CENTERED INTAKE
SO THAT IS THE FIRST LAYER IN
ENCOUNTERING THIS MODEL AND
EVIDENCE INFORMED PROTOCOL
GUIDED CARE, WE ARE WORKING ON
DEFINING THOSE PROTOCOLS,
PROACTIVE KREENING, COORDINATED
BRAIN HEALTH AND LATE POST
INJURY SERVICES AS NEEDED, A
RISK BASED FOLLOW UP AND
INFORMAL TELEPHONE SUPPORT, RISK
INTENSITY ASSESS AM, REMEMBER, I
MENTIONED THE SOCIAL
DETERMINANTS OF HEALTH, THE CASE
MANAGEMENT, THE SUPPORTED MANAGE
AM, THE DISEASE MANAGEMENT AND
CASE MANAGE AM AND THAT WE WOULD
BE DETERMINING THAT BASED ON
SOCIAL DETERMINANTS OF HEALTH,
MEDICAL COMPLEXITY AND ABILITY
TO SELF-MANAGE.
SYSTEMIC COMPREHENSIVE
EDUCATION, SUPPORTED
SELF-MANAGEMENT AND A CASE
MANAGEMENT AND RESOURCE
FACILITATION TO HELP PEOPLE
NAVIGATE THE SYSTEM AND THE
COMMUNITY BARRIERS.
SO AT THIS POINT WE ARE AT THE
POINT OF CREATING OR
IMPLEMENTING THESE FEASIBLE
PROJECTS.
WE HAVE 13 FEASIBILITY PROJECTS,
CLINICALLY, WE ARE DEVELOPING
SOME CLINICAL CARE PROTOCOLS, WE
ARE IN THE PROCESS OF CREATING A
CASE DEFINITION FOR CHRONIC
BRAIN INJURY.
WE ARE TESTING OUT SOME EXISTING
SELF-MANAGEMENT APPROACHES FOR
CHRONIC DECS THAT THEY ALREADY
EXIST BUT WE'RE NOW HAVING
PEOPLE WITH BRAIN INJURY ENGAGED
IN THE STANFORD CHRONIC DEC
SELF-MANAGEMENT PROGRAM AND TO
SEE WHAT KIND OF BARRIERS AND
EXPERIENCE THEY HAVE.
WE ARE LOOKING AT WHAT IT TAKES
TO PERFORM SELF-MANAGEMENT AND
TESTING OUT A MOBILE APP TO SEE
IF THAT MIGHT HELP THEM WITH
SELF-MONITORING.
STRUCTURALLY WE ARE DOING A
SURVEY TO FIND OUT WHAT KIND OF
CARE PEOPLE HAVE IN PLACE, DO
THEY HAVE A PRIMARY CARE
SPECIALIST, OR A BRAIN INJURY
SPECIALIST AND WHY OR WHY NOT?
WHY DO THEY NOT HAVE A BRAIN
INJURY CARE SPECIALIST?
WHY DON'T THEY HAVE A PRIMARY
CARE SPECIALIST SO WE CAN
ANALYZE THOSE OPTIONS.
SO WE ARE ANALYZING DATA FROM
THE VA TO LEARN MORE ABOUT THE
SUCCESSES THE VA HAS HAD IN
THEIR IMPLEMENTATION OF VERY
INTENSE CONTINUITY OF TBI CARE
COMBINED WITH SPECIALTY CARE.
WE ARE USING DATA FROM A PC ORI
STUDY CALLED THE BRIGHT STUDY,
TO LOCK AT SOCIAL DETERMINANTS
OF HEALTH ON HEALTHCARE
UTILIZATION IN THE FIRST 12
MONTHS POST INJURY AND WE'RE
ALSO USING THE BRIGHT STUDY TO
LOOK AT RESOURCES THAT PEOPLE
HAVE USED AND THEIR ACCESS TO
THOSE RESOURCES IN
URBANNIVERSEUS RURAL
POPULATIONS.
AND WE ARE DOING--SCOPING REVIEW
OF THE PREPARE TOOL, THE PREPARE
TOOL IS THE SOCIAL DETERMINANTS
OF HEALTH SURVEY, AND SO WE'RE
LOOKING AT JUST WHAT THE
LITERATURE SHOWS TO SUPPORT THAT
TO SEE IF WE CAN USE THAT AS
PART OF OUR RISK ARK
ASSESSESMENT.
WE NASHA LED BY REBECCA WOLFKILL
IS DOING THE ARK ASSESSESMENT OF
STATE PARTNERSHIPS TO ASSESS
THEIR PARTICIPANTS THAT COME IN
SO WE CAN LEARN FROM FROM THAT,
THEIR INTAKE ASSESSMENTS AND SEE
IF THAT WILL HELP US AND WE HAVE
A MEDICAID MANAGED CARE ORGANIZE
THAT'S WORKING WITH US TO SEE,
WE'RE LOOKING AT THEIR DATA ON
IT SEE THE NUMBERS OF PEOPLE
WITH BRAIN INJURY AND LOOKING AT
TRYING TO HELP IMPLEMENT
SCREENING AND SEEING WHAT THE
FINANCIAL SMLICATIONS WOULD BE
AND IMPLEMENTING SUCH A MODEL.
SO THAT BRINGS US TO THE NEXT
STEPS THAT WE'RE LOOKING FORWARD
TOWARDS, IMPLEMENTING AND
SUSTAINABILITY, WE HAVE A LOT TO
DO TO IDENTIFY SOME OF THE
OBSTACLES AND SOLUTIONS FOR
HEALTHCARE REIMBURSEMENT, THERE
ARE A LOT OF BARRIERS WE NEED TO
IDENTIFY AND FIGURE OUT
SOLUTIONS FOR AND INTEGRATION
BETWEEN THE MEDICAL COMMUNITY
AND THAT COMMUNITY PIECE THAT IS
SO OFTEN NEGLECTED CONTINUING TO
ENGAGE STAKEHOLDERS AND REALLY
USE THE STAKEHOLDER ANDS HELPING
WITH THE ADVOCACY FOR THIS.
FURTHER DEVELOPMENT OF PROTOCOL
ANDS PROCEDURES TO MAKE THIS
HAPPEN AND OF COURSE WITH ANY
GOOD RESEARCH, YOU NEED MORE
FUNDING TO PURSUE THE PLANNING
OF FUNDING THAT'S NEEDED AND
WE'RE RYING TO FIGURE OUT, AT
FIRST WE THOUGHT IT WILL WILL BE
A PRAGMATIC CLINICAL TRIAL AND
WE'RE REALIZING THAT A WAY AHEAD
FOR US, WE REALLY HAVE MORE THAN
WE NEED TO DO TO ACTUALLY
DEVELOP THIS, SO, TRYING TO
FIGURE OUT THE BEST WAY FORWARD
TO KEEP THIS WORK GOING.
SO IN SUMMARY, CHRONIC CARE
MODELS CERTAINLY HAVE BEEN FOUND
TO BE SUCCESSFUL IN HELPING
OTHER DISEASES AT LOWER COST AND
LOWER THE IMPACT, NEG5 IMPACTS,
AND WE WOULD LOAMACYIC TO DO THE
SAME THING FOR BRINE INJURY.
THERE'S A LOT WE NEED TO DO TO
MAKE THAT HAPPEN IN ADDITION TO
THE SUSTAINABILITY ISSUES WE
NEED TO ADDRESS, WE ALSO NEAD TO
IDENTIFY HOW TO RISK-STRATIFY
AND HOW TO--1 OF THE OTHER
THINGS THAT IS REALLY IMPORTANT
IN OUR OPINION IS TO GET BRAIN
INJURY TRULY RECOGNIZED AS A
CHRONIC CONDITION, SUCH FOR
EXAMPLE, THAT CMS RECOGNIZES IT
IS A CHRONIC CONDITION TO BE
ABLE TO TAP INTO ACCESS TO DATA
AND SERVICES AND ALSO FOR
SURVEILLANCE.
ALSO THERE'S A LOT OF TALK USING
LEARNING HEALTH SYSTEMS TO HELP
US USE DATA AND INTEGRATED CARE,
AND IN FACT, AT THE NATIONAL
ACADEMY OF SCIENCE ROADMAP
POINTS OUT THE IMPORTANCE OF A
LEARNING HEALTH SYSTEM FOR THE
FUTURE OF BRAIN INJURY, AND THAT
WOULD BE IMPORTANT HERE FOR THIS
CHRONIC CARE MANAGE AM AS WELL.
AND FURTHERING THESE CONNECTIONS
TO RESOURCES IN THE COMMUNITY
AND LASTLY THERE'S A VERY
SHORTAGE OF BRAIN INJURY
PROFESSIONALS, THERE'S A
SHORTAGE OF HELT CARE
PROFESSIONALS PERIOD ACROSS THE
DIFFERENT DISCIPLINES AND IT IS
DEFINITELY THE CASE IN BRAIN
INJURY.
SO NEEDING TO BUILD THAT
CAPACITY.
THANK YOU.
>> THANKS SO MUCH, FLORA.
QUESTIONS FROM EITHER THE
INDIVIDUALS WHO ARE REMOTE OR
AROUND THE TABLE?
NI'LL TAKE IT.
THANK YOU FOR A VERY, VERY NICE
PRESENTATION.
YOU KNOW THERE'S SOME DATA TO
SUGGIEST THAT DANCE AND MUSIC
CAN BE NOT ONLY A FORM OF
TREATMENT BUT IT ALSO IT CAN
PROMOTE ENGAGEMENT FOR BEHAVIORS
AND MIGHT BE A FACTOR HERE AND I
WONDER WHAT ARE YOUR THOUGHTS ON
MUSIC AND DANCE AS A PART OF THE
PROCESS?
>> YEAH, AND THERE IS A LOT OF
RESEARCH ON MUSIC AND DANCE AND
VARIOUS DIFFERENT HEALTH
CONDITIONS AND I DON'T
NECESSARILY KNOW THE LITERATURE,
BUT CERTAINLY, I THINK THAT NOT
ONLY MAY IT TAP INTO DIFFERENT
BENEFITS BUT IT ALSO TAPS INTO A
LOT OF THESE BRAIN HEALTH,
RIGHT?
WE MENTIONED MOVEMENT, EXERCISE,
SOCIAL ENGAGEMENT, SO I THINK IT
WOULD BE AN EXCELLENT MEANS OF
TAPPING BO THE ENGAGEMENT THAT
WE MENTIONED.
>> THERE'S AN INCOMING MEETING
THIS MONTH ON THIS TOPIC AND WE
WOULD ENCOURAGE YOU TO
PARTICIPATE.
>> OTHER THOUGHTS IN THOUGHTS?
>> FLORA, YOU USED THE TERM
ACTIVATED QUITE A FEW TIMES CAN
I GET A BETTER DEFINITION OF
THAT, I WANT TO MAKE SUREIME
UNDERSTANDING THAT RIGHT.
>> YEAH, SO WE DID.
SO ACTIVATED PROFESSIONALS THAT
WE ARE AWARE, THAT WE KNOW
WHAT'S IN FRONT OF US SO THAT WE
CAN RECOGNIZE IT AND THAT WE'RE
READY TO IDENTIFY AND TREAT
WHAT'S IN FRONT OF US AND THEN
I'LL USE THE TERM ACTIVATED FOR
PARTICIPANTS IN DOING
SELF-MANAGEMENT.
THEY NEED TO, BEING ABLE TO KIND
OF LAY OUT THE STORY FOR THEM
AND ENGAGE THEM SUCH THAT THEY
REALIZE WHAT HAY CAN BE WORKING
ON AND HAVING THEM READY FOR
CHANGE.
>> YEAH, THIS SEEMS REMINISCENT
OF A LOT OF OTHER CONDITIONS WE
DEAL WITH WHERE OUR HEALTHCARE
SYSTEM IS SO FRONT LOADED FOR
THE ACUTE AND UNDERVALUES THE
NEED FOR SUPPORT INTO THE
CHRONIC PHASE BECAUSE PEOPLE
HAVE SO MANY OFFRAMPS AND YOU
KNOW OUR HEALTHCARE SYSTEM
DOESN'T ALWAYS APPRECIATE THE
IMPORTANCE OF THAT INVESTMENT
AND ON TOP OF THAT YOU HAVE
PEOPLE WHOSE VERY ABILITY TO
ADVOCATE FOR THEMSELVES
EXECUTIVE FUNCTION CAN OFTEN
BEING COMPROMISED AS PART OF
THEIR HEAD INJURY.
SO I'M JUST THINKING ABOUT WHEN
YOU FIRST HAVE MACHINE YOU'RE
DEALING WITH, A FAMILY, A
PERSON, HOW WELL CAN YOU PREDICT
THEIR TRAJECTORY AND SET THEM
OFF ON THE CORRECT COURSE OR HOW
MUCH DOES THE THING SURPRISE YOU
IN THE CLINIC IN TERMS OF THE
NEED AND SUPPORT FOR PEOPLE?
BECAUSE IT SEEMS LIKE IT'S SO
IMPORTANT TO GET THEM TO HAVE
THAT--YOU KNOW TO ADVOCATE FOR
THEM AND GET THAT SUPPORT IN THE
FAMILY AND THE COMMUNITY TO HELP
THEM NAVIGATE THE SYSTEM WHEN
THEY'RE VARIABILITY TO ADVOCATE
IS COMPROMISED.
>> EXCELLENT POINT AND WE REALLY
CAN'T PREDICT THAT OR WE HAVEN'T
BEEN GOOD AT PREDICTING IT.
I THINK OFTEN TIMES WHETHER IT'S
A LACK OF RESOURCES OR A LACK OF
PREDICTION, PEOPLE LOOK GOOD,
AND THEY'RE KIND OF JUST SENT
ALONG THEIR WAY AND MAYBE EVEN
PEOPLE WITH THE INJURY MAY NOT
REALIZE, THEY MAY NOT REALIZE
THAT THEY NEED THAT INFORMATION
AND SO YOU MAY BE PROVIDING
INFORMATION BUT NOT AT THE RIGHT
TIME.
SO A LOT OF PEOPLE ARE KIND OF
LIKE, YOU ARE DOING WELL, YOU
DON'T NEED ANYTHING ELSE AND
THEN AT THE SAME TIME, SO MANY
OTHERS ARE GIVEN A PROGNOSEIS
THAT THERE'S NOTHING WE CAN DO
AND THEN, LIMITED INFORMATION
AND RESOURCES FOR THOSE
INDIVIDUALS AS WELL.
SO WE ARE REALLY NOT GOOD AT
PREDICTING AND WHAT WE REALLY
NEED TO BE DOING IS GIVING AN
ONRAMP FOR EVERYONE SUCH THAT
PEOPLE CAN HAVE THE FOLLOW UP
WHEN THEY'RE READY AND BEING
NEEDED AND WHEN THEY'RE ABLE TO
RECOGNIZE WHAT THEY NEED.
AND LUCKILY A LOT OF WORK FROM
THE NASEM FORUM IS MAPPING ON TO
THIS AS WELL.
>> HI, FLORA.
THANKS SO--THIS IS GREAT AND A
LOT OF TERRITORY THAT YOU'RE
COVERING AND IF I UNDERSTOOD
CORRECTLY, SO THIS IS THE FOLKS
WHO HAVE UNFORTUNATELY
EXPERIENCED NEUROTRAUMA, BRAIN
TRAUMA AT WHATEVER AGE IN THEIR
LIFE, SO I'M THINKING ABOUT THE
YOUNGER POPULATIONS, SCHOOL
AGED, COLLEGE AGE, HAVE YOU
THOUGHT ABOUT THAT IDEA OF
STRATIFYING OR SORT OF A LIST OF
WHO THE PARTNERS WOULD BE THAT
CAN ASSIST IN THE CARE, THE
DEVELOPMENT, THE NEEDS OF FOLKS,
YOU KNOW WITHIN A SCHOOL SYSTEM
OR WITHIN A COLLEGE COMMUNITY,
COMMUNITY COLLEGE ENVIRONMENT
THAT THERE MIGHT BE DIFFERENT
PARTNERS THAT MIGHT COME IN TO
PLAY AND BE HELPFUL DEPENDING ON
THE AGE OF THE PERSON WHEN THEY
EXPERIENCE THE NEUROTRAUMA.
>> GREAT POINT.
SO DEFINITELY, IDENTIFYING AND
ACTIVATING OUR PARTNERS WILL BE
IMPORTANT.
THE--WE HAVEN'T GOTTEN THAT FAR
BUT OUR PRIORITY IS REALIZING
THE COMMUNITY AND THE PARTNERS
HAVE TO BE A PART OF THIS,
THAT'S WHERE PEOPLE--YOU'RE
LIVING IN YOUR COMMUNITY AND IT
CAN'T JUST ALL BE A MEDICAL
MODEL SO WE HAVEN'T GOTTEN TO,
YOU KNOW WHO ARE THE PARTNERS
AND WHAT ARE WE DOING TO CHANGE
THINGS, BUT WE WILL.
>> OH, OKAY, SORRY I GOT A
LITTLE AHEAD OF YOU ON IT
BECAUSE I'M THINKING WELL ON AN
ACADEMIC ENVIRONMENT, YOU KNOW
THERE'S MORE PEOPLE TO BRING TO
BEAR TO HELPING THAT INDIVIDUAL
OUT AND I UNDERSTAND THE DEARTH
OF CARE PROVIDERS OF ALL TIMES
IN THIS COUNTRY.
>> KATHLEEN, AND THEN FRANCISCO.
>> I LOVE HOW YOU LAID OUT THE
STRUCTURE OF THIS BUT WHAT I
FEEL LIKE I HAVEN'T HEARD YOU
BRING UP IS THE INFLUENCE OF
REGULATORS AND HOW THAT MIGHT
PROVIDE FUNDING OR INCREASE THE
POTENTIAL FOR CAREGIVERS TO BE
AVAILABLE?
IS THAT TRUE OR LIKE REGULATORS
ARE YOU--IS THERE ANYWAY TO
INCREASE INSURANCE COVERAGE FOR
SOME OF THIS SO THAT THERE WOULD
BE A DEMAND FOR MORE CAREGIVERS
THAT COULD MAKE A LIVING DOING
THE WORK YOU NEED FOR THESE
PEOPLE?
>> AGAIN, THIS IS--SO, WE'RE IN
YOUR--JUST STARTING YEAR 4 OF
THIS BIG GRAND VISION.
BUT I'M TAKING NOTES BECAUSE
THESE ARE EXACTLY THE THINGS WE
NEED TO DO AND YOU KNOW
MENTIONED, FIGURING OUT THE
FUNDING SO THAT'S A GREAT POINT
AND I AM REMEMBERING THAT MAYBE
FUNDING FOR CAREGIVERS MAY BE AN
IMPORTANT PIECE.
>> AND I FEEL LIKE, FROM MY
EXPERIENCE AT LEAST, GETTING
THEM INVOLVED EARLY SO THAT THEY
FEEL LIKE THEY'RE PART OF THE
PROCESS AND NOT JUST THOUGHT OF
LATER WHEN THEY'RE NEEDED
SOMETIMES IS HELPFUL, YOU KNOW,
STILL A TOUGH ROAD BUT I THINK
THIS IS REALLY FANTASTIC.
>> FRANCISCO?
>> THANK YOU.
>> YES, GOOD MORNING, THIS IS
CERTAINLY A VERY BROAD VIEW OF
ALL THE CHALLENGES AND I JUST
WANT TO FOLLOW UP A LITTLE BIT
ON THE QUESTION ABOUT YOU KNOW
PEOPLE OF A YOUNGER AGES OR
EVEN, EVEN ADULTS OFTEN TIMES
RETRAINING, MAYBE A DIFFERENT
PROFESSION IS WHERE THE
INDIVIDUAL WANTS TO GO AND TBI
HAS AN EFFECT ON LEARNING.
SO HOW DO YOU SEE THE
EDUCATIONAL ENVIRONMENT, SORT OF
BEING ACTIVATED TO EMBRACE AND
HELP PEOPLE WITH THESE
CONDITIONS.
IT'S A BIG QUESTION BUT THE
EDUCATION OF THESE INDIVIDUAL
SYSTEM WHAT WILL HELP THEM MOST
AND HELP THEM A LOT IN LIFE'S.
NTHAT'S REALLY ANOTHER EXAMPLE
WHERE WE NEED TO IDENTIFY THE
COMMUNITY PARTNER ANDS HOW WE
CAN WORK TOGETHER TO IMPROVE
THINGS.
SO, THIS WILL BE, YOU KNOW IT'S
VISIONARY RIGHT NOW, NOW TRYING
TO PUT SOME PIECES TOGETHER, AND
THE PIECES WILL CONTINUE TO
BE--TO EVOLVE AS WE'RE ABLE TO
DO SO AND YOU POINTED OUT
ANOTHER EXCELLENT AREA WHERE WE
WILL NEED TO PARTNER.
>> THANK YOU.
THIS IS EXCELLENT WORK AND AS A
PROVIDER IN A NEUROOUTPATIENT
CLINIC, I SEE HOW MANY PEOPLE
FALL THRU THE CRACKS AND HOW
THIS COULD HELP PEOPLE AND THEIR
FAMILIES IN THE ISES.
I'M CURIOUS HAVE YOU LAID THIS
MODEL OUT IN A PAPER YET.
I THINK IT WOULD BE HELPFUL TO
SEE IF YOU HADN'T, I WOULD
ENCOURAGE IT BECAUSE I THINK
IT'S A NEW WAY OF THINKING
THAT'S REALLY VISIONARY AND I
THINK THAT OUR FIELD IN OTHER
AREAS COULD BENEFIT FROM SEEING
IT, SO FLORA, SO I DID A QUICK
PUB MED SEARCH AND IT'S EARLY
BUT I EVAPORATE SEEN IT.
>> SO WE HAVE NOT.
WE'VE BEEN PRESENTING IT
EVERYWHERE AND TRYING TO GET
INPUT AND BUY-IN AND ALL THAT.
WE DID THE PAPER IN 2013 THAT WE
WILL UPDATE SOON AND MAYBE IT
BELONGS IN THERE BUT IT REALLY
MAY BE ITS OWN.
SO THANK YOU.
YES WE WILL.
>> JUST FOLLOWING UP ON DAWN'S
COMMENT.
AS YOU WERE PRESENTING THIS, I
THINK ITS APPLICATION IS BROAD
AND ARE THERE OPPORTUNITIES FOR
US TO BRING TOGETHER OTHER
DISCIPLINES?
I'M THINKING SPINAL CORD,
STROKE, THESE--MENTAL HEALTH,
YES.
DEMENTIA, MULTIPLE SCLEROSIS,
THESE ARE CRITICAL PRINCIPLES
THAT ARE WIDELY APPLICABLE.
AND YOU KNOW PERHAPS AS WE
BRAINSTORM WHAT WE CAN DO, WE
CAN FIND WAYS TO BREAK DOWN
SILOS AND USE THE FOUNDATION
THAT YOU'RE BUILDING MORE
BROADLY.
>> I'M DPLAD YOU MENTIONED THAT,
OUR HEALTH IN OUR COMMUNITY ARE
SO HARD TO NOVEMBERIGATE AND IT
REALLY SHOULDN'T BE CONNECTICUT
DITION, FIGURING IT OUT AND THEN
FIGURING IT OUT, AND THEN
ANOTHER CONDITION AND FIGURING
IT OUT AND CREATING NEW MANAGE
WILL ACCIDENT ARE IT SHOULD BE
ABOUT NAVIGATING AND LIVING WITH
DISABILITY, WE HAD CONVERSATIONS
OF JUST ACROSS A SPINAL CORD
INJURY AND BURN MODEL SYSTEMS
BECAUSE BURN IS ALSO A CHRONIC
INJURY, BUT REALLY, WE JUST NEED
TO BE MOVING THE MEDICAL SYSTEM
AND THE COMMUNITY TOGETHER.
>> GREAT, I'M SO GLAD YOU
MENTIONED ABOUT OTHER DISCIPLINE
ANDS I SAW FLORA THAT YOU'RE
INGAUGING WITH
DR. [INDISCERNIBLE], THE PMR DOC
AND HE'S THE CO-LEADOT CHRONIC
[INDISCERNIBLE] NEUROTRAUMA
CENTER AND WITH THE VA AND
D.O.D. BUT WITH THE MULTIPLE
PROFESSIONS AND THE SORT OF
MULTIPLE CONDITIONS, SO I KNOW
YOU'RE GOING TO TALK WITH
DR. [INDISCERNIBLE], THE
POLYTRAUMA CENTERS IN VA, BRING
TOGETHER THE INTERDISCIPLINARY
GROUPS TO WORK WITH THE VETERANS
AND IN FACT, PRIOR TO THE
CURRENT CONFLICTS THEY WERE TBI
CENTERS AND THEY HAD TO RAPIDLY
RAMP UP AND BECOME TRAUMA
CENTERS BA UNITED STATES SERVICE
MEMBERS WERE COMING BACK WITH
MORE THAN 1 KIND OF YOUR AND SO
YOU COULDN'T JUST DO THAT NARROW
SLICE.
SO THEY RAPIDLY MOVED TO
POLYTRAUMA, AND NOW THEY'RE
POLYTRAUMA CENTERS, SO THAT'S
GREAT THAT YOU WILL TALK TO DAVE
[INDISCERNIBLE] ABOUT THAT.
IT'S A TEAM, RIGHT, IT'S A TEAM.
>> YEAH, FLORA, ALSO YOU'VE BEEN
A LEADER WITH THE--AS PEOPLE
WERE SAYING WITH THE NIGHEDLER
MODEL SYSTEMS AND I WAS
WONDERING IF YOU COULD REFLECT A
LITTLE BIT ABOUT THE POWER AND
WHAT NIGHEDLER, THEIR VIEW POINT
AND THE WAY THEY SUPPORT
RESEARCH, HOW THAT HELPS YOU IN
YOUR TBI RESEARCH AND THE NIH,
THE CULTURES ARE SIMILAR AND
DIFFERENT ISSUES SO COULD YOU
HIGHLIGHT A LITTLE BIT ABOUT, I
KNOW YOU HAD NIH CONTECHNOLOGY
ORGANIZATIONS AS WELL, AND ABOUT
HOW WE CAN USE THEM THROUGH OUR
BEST ABILITIES?
>> YEAH, AND I--TO FOCUS THE
TALK 1 OF THE SLIDES, I DIDN'T
LIST IS SO THIS EFFORT, HAS COME
ALONG OVER THE YEARS, A LOT
OF--LARGELY INFORMED BY MODEL
SYSTEMS DATA SO THAT NATIONAL
DATABASE OF BEING ABLE TO FOLLOW
PEOPLE'S LIFE LONG COURSE WAS
VERY IMPORTANT.
THIS PARTICULAR GRANT RELATIVELY
SMALL AMOUNT OF MONEY BUT WHAT
WE DID IS WE PUT TOGETHER, 7--WE
17 SITES SO MY GRANTS ADMIN
TRAITOR HAS 17 DIFFERENT
CONTRACTS THAT WE HAS TO MANAGE
FOR A RELATIVELY SMALL AMOUNT OF
MONEY BUT IT'S ALLOWED US TO
COME TOGETHER, IT'S ALL THE
MODEL SYSTEMS SITES PLUS THE
TAMPA VA AND WE'VE COME TOGETHER
WITH ALL OF THESE BRAINS TO BE
ABLE TO USE ALL THAT EXPERTISE
EMPLOY AS YOU KNOW RALPH, NIH
HAS ALSO COLLABORATED WITH THE
MODEL SYSTEMS IN REGARDS TO
LEARNING ABOUT THE TYPES OF CARE
WE ADMINISTER IN PATIENT THAT
SET SOMEONE UP FOR SUBASSESSES,
TRYING TO FIGURE OUT WHETHER THE
DIFFERENT ELEMENTS OF CARE
CERTAINLY NIH AND NIDLER WORKING
HAND IN HAND TO TRY TO USE AND
GET OUR DATA AND MOVE THE FIELD
FORWARD.
WE ARE AND SHOULD BE WORKING
HAND IN HAND TO DO THAT.
I THINK IDENTIFYING THESE THINGS
IT SHOULDN'T BE JUST 1
DIAGNOSIS, I THINK WITH NIDLER
OUR FUNDING IS OFTEN TIMES THE
BRAIN INJURY MODEL SYSTEMS OR
SPINAL CORD MODEL SYSTEMS, I
THINK OF COURSE YOU GUYS KNOW
BETTER THAN I DO AS FAR AS
OPPORTUNITIES FOR COLLABORATION
EMPLOY.
>> THANK YOU, AGAIN.
IF ANYONE ELSE AROUND THE TABLE
IS EXPERIENCING THE SAME THING I
AM, MY MIND IS TILL GOING WITH
POSSIBILITIES AND WHAT WHAT WE
CAN DO.
BUT LET'S MOVE ON TO THE NEXT
SESSION AND RALPH, YOU WERE
GOING TO INTRODUCE?
>> OKAY, SO AS PART OF THE
DEMOCRACY OF THE BOARD AT OUR
PREIOUS DISCUSSIONS, THE BOARD
SAID THEY WANT TO BE MORE ABOUT
MUSK LO SKELETAL AND INJURY
ISSUES THAT WE HAVE A TENDENCY
TO FOCUS SOMEWHAT MORE ON
NEUROREHAB, STROKES, SPINAL CORD
INJURY, TBI, CEREBRAL PALSY AND
WE WANTED TO SPREAD THAT LOVE TO
MUSK LO-SKELETAL ISSUES AND TO
START THAT DISCUSSION WE
ENVIETED 3 PEOPLE WHO WILL GIVE
US A BIT OF BACKGROUND, START OF
DISCUSSION ON THE ISSUES THAT
COME UP IN TERPS OF INJURY
RESEARCH AND THE WAY WE LAID IT
OUT WE HAVE TEEF GOLMAN WHO IS A
BIOENGINEER AND SENIOR SCIENTIST
AT THE DOA, I'M SORRY D.O.D.
DEPARTMENT OF DEFENSE AND THE
VA, I'M SORRY, GOLDMAN, HE'S
TAKEN THE TIME TO COME HERE AND
I--OKAY, SO STEVE AND I HAVE
BEEN E-MAILING BACK AND FORTH.
AND HE'S AT THE D.O.D.-VA
EXTREMITY TRAUM AND AMPUTATION
CENTER OF EXCELLENCE AND HE WILL
START THE DISCUSSION WITH
BACKGROUNDOT MILITARY CULT NUR
VA AND SOME OF THE RESEARCH THEY
FUND ON MUSK LO SKELETAL MUSCLE
INJURIES AND THEN WE WILL HAVE
RIANN P A LMIERI-SMITH WHO IS A
ATHLETIC TRAINING AT THE
UNIVERSITY OF MICHIGAN AND
TRECTOR OF O OTHER O PEDIC REHAB
AND BY O MECHANICS.
SHE WILL TALK TO US SPECIFICALLY
ABOUT SPORTS INJURIES AND HOW WE
TRY TO SUPPORT THEM TO THE
DEMOGRAPHICS AND SOME OF THE
RESEARCH ISSUES AND THEN WE WILL
HAVE LINDA VAN DILLEN, LINDA IS
A PROFESSOR OF PHYSICAL THERAPY
AT WASHINGTON UNIVERSITY IN
ST. LOUIS IN THE INTERACTION OF
BIOMECHANICAL AND NEUROLOGICAL
FACTORS IN MECHANISMS UNDERLYING
MUSK LO SKELETAL PAIN AND SHE
WILL TALK TO US ABOUT THE BACK
INJURY AND THE BROADER FIELD OF
PAIN TREATMENT AND THIS IS ONLY
TO START A DISCUSSION AND GIVE
US A TASTE OF SOME OF THE ISSUES
OF DEMOGRAPHICS AND SOME OF THE
ISSUES IN TERMS OF INJURY TO
SHIFT THE DISCUSSION A LITTLE
BIT AND BROADEN IT A BIT AND WE
LOOK FORWARD TO WHAT COMES OUT
OF THAT SO STEPHEN GOLDMAN,
[LAUGHTER]
, SORRY, WHY DON'T YOU START US
GOING.
>> OKAY, THANK YOU FOR HAVING
ME TODAY AND WE WILL TALK ABOUT
SOME ISSUES RELATED TO COMBAT
TRAUMA EXTREMITY RESEARCH.
THERE WE GO.
SO THIS IS MY PERSPECTIVE, THE
D. O. LIKES US TO DISCLAIM THAT
THIS IS NOT OFFICIAL STATEMENTS
BUT THAT OF MYSELF AS A
RESEARCHER EMPLOYED BY THE
D.O.D.
SO FIRST I ALWAYS LAKE TO START
OFF BY ACKNOWLEDGING ALL MY
COLLABORATOR THAT HELPED WITH A
NUMBER OF DIFFERENT PROJECTS
SOME OF WHICH YOU WILL SEE HERE
TODAY.
MY TEAM IS LOCATEDDA THE UNIFORM
SERVICES UNIVERSITY WHICH IS
JUST ACROSS THE STREET FROM THE
NIH AND SOME OF OUR SURGICAL
PARTNERS ARE ACTIVE SURGEONS AT
WALTER REED IN BETHESDA.
SO WITHIN THE D.O.D. THE
STRATEGIC DRIVERS OF RESEARCH
ARE REALLY FROM A TOP DOWN
APPROACH VERSUS PERHAPS WHAT YOU
ALL ARE MORE FAMILIAR WITH WHICH
IS MORE OF AN INVESTIGATOR
INITIATED APPROACH.
SO WHAT HAPPENS IN THE D.O.D. IS
THEY PRODUCE THESE STRATEGIC
PRIORITY DOCUMENTS AND IT LAYS
OUT WHAT THE FOLKS UP AT THE
HIGHER LEVELS THINK ARE GOING TO
BE THE NEEDS OF THE MILITARY
INTO THE COMING DECADES AND AS A
RESULT, THE FOCUS ON MANY OF THE
RESEARCH ENDEAVORS IS ON
OPERATIONAL READY WHICH IS TO
ENHANCE THE HEATHAL OF THE
FIGHTING FORCE AND RETURNED
SERVICE MEMBERS TO DUTY AS
QUICKLY AS POSSIBLE.
WE DO THIS BY IDENTIFYING
CLINICAL GAP AREA ANDS THAT IS A
PROCESS THAT IS DONE BETWEEN THE
PORTFOLIO MANAGERS AND THE
CAREGIVERS THEMSELVES AT THE
TREATMENT FACILITIES.
AND I WOULD SAY THERE IS AN
INTENSE FOCUS ON
TRANSLATABILITY, SO THE IDEA
HERE IS SEE A NEED, FILL A NEED
AND THE RESEARCH IS THE MEANS TO
FILL THAT NEED WHETHER IT BE
KNOWLEDGE OR MATERIAL PRODUCTS.
SO IN MY WORLD I'M FOCUSED
PRIMARILYOT EXTREMITIES, MUSKUE
LO SKELETAL TRAUMA.
THIS SUMS UP TEMPORARY CONFLIGZ
AND WHAT WE'VE SEEN, SO AS CASE
FATALITY RATE HAS DROPPED OVER
THE MOST RECENT CONFLICTS, YOU
KNOW THAT'S A RESULT OF IMPROVED
BODY ARMOR, ARMORED VEHICLES,
BASICALLY JUST TECHNOLOGICAL
IMPROVEMENTS ACROSS THE BOARD AS
WE SEE THOSE FACAS TAILITY
DROSOPHILA IN THE GREAT THING
WE'VE SEEN A GREAT INCREASE IN
THE SEVERITY OF INJURIES
SOLDIERS ARE COMING HOME WITH
AND PREDOMINANT LYE THOSE ARE
AFFECTING THE EXTREMITIES, IE
THE AREAS NOT COVERED BY BODY
ARMOR.
SO MY GROUP, I'M PART OF THE
EXTREMITY TRAUMA AND AMPUTATION
CENTER FOR EXCELLENCE AND WOE
DIVIDE OUR RESEARCH TO TRI TO
COVER THE FULL SPECTRUM OF CARE
FOR PATIENTS WITH AMPUTATION,
LIMB CONSTRUCTION AND OTHER
EXTREMITY TRAUMAS.
SO WE KIND OF BREAK THIS UP INTO
4 MAIN FOCUS AREAS WHICH IS
ADVANCE REHABILITATION
SCIENTISTS MEDICAL AND CERVICAL
INTERVENTIONS WHICH IS THE AREA
I'M IN, ADVANCED PROSTHETIC ANDS
EPITEEMIO LOGIC RESEARCH WHICH I
HAVE ALSO DOUBLE INDEED AS YOU
WILL SEE IN A FEW SLIDES.
SO THIS IS A FAIRLY SIMPLE
PICTOGRAPH OF THE WAY THAT I
INTERVIEW EXTREMITY YOURS AND
TRAUMA.
SO WITHIN THE SCOPE OF SEVERE
EXTREMITY TRAUMA YOU HAVE
AMPUTATIONS IN THE BIG BLUE
CIRCLE AND WE WILL TALK ABOUT
THOSE FIRST AND IN THE 2 RED
CIRCLES HAVE YOU THE FIELD CALLS
LIMB SALVAGE AND IT'S MORE
AMBIGUOUS OF A TERM AND A LOT
HARDER TO STUDY IN MY OPINION
THAN AMPUTATIONS SIMPLY BECAUSE
IT'S A BIT MORE AMBIGUOUS.
SO FOCUSING FIRST ON
AMPUTATIONS, AS YOU CAN SEE
HERE, THIS IS A STUDY PRODUCED
BY 1 OF MY COLLEAGUES, IT WAS A
FOLLOW UP STUDY THAT WAS PUB
LESH INDEED 2018 AND IT JUST
LAID OUT, THE NUMBER OF COMBAT
RELATED AMPUTATIONS THAT WERE
OBSERVED DURING MOST RECENT
CONFLICKS AND YOU CAN SEE KIND
OF SEE A PHASE WHERE THE AMPUE
TAIGS KIND OF FOLLOW INCREASE IN
ACTIVITY OVERSEAS BETWEEN 2003
AND 2013 EFFECTIVELY, A DECADE
OF CONFLICT AND IT FALLS OFF AS
WE BROUGHT OUR ACTIVITIES BACK
DOWN.
THE FACT THAT THIS WAS A FOLLOW
UP STUDY TO A PRIOR STUDY THAT
WAS PERFORMED IN 2010, KIND OF
ILLUSTRATES THE FACT THAT
THASMUE TEE POPULATION AND
RIGHTFULLY SO, IT'S BEEN VERY
WELL SERVED BY THE MILITARY
SETTLE SYSTEM AND IT'S BEEN VERY
WELL STUDIED.
SO FROM ALL THAT EFFORT WHAT WE
FOUND IS THAT WE'VE COME A LONG
WAY, SO HERE I SHOW SOME
SURGEONS FROM THE CIVIL WAR
TIMES AND UP TO THE COVER OF
SCIENCE TRANSLATIONAL MEDICINE
FROM A RECENT ISSUE THAT LOOKS
AT LIMB RESTORATION ADVANCE
TECHNIQUES TO COMBAT LIMB LOSS.
SO, 1 OF MY COLLEAGUES RETIRED
COLONEL POTTER, WE SPOKE WITH
HIM ABOUT WHAT IS IT THAT PEOPLE
SHOULD KNOW ABOUT AMPUTATION AND
HIS ADVICE IS DO A GOOD 1
EFFECTIVELY.
AND SO, WHEN HE THINKS ABOUT
DOING GOOD AMPUTATION, THESE
SOME ARE SOME OF THE FACTORS WE
LISTED OUT AS WAYS TO DO A GOOD
AMPUTATION, TO BE BE VERY
THOUGHTFUL ABOUT THE PROCESS,
THINK ABOUT THE LEVEL AT WHICH
THE AMPUTATION WILL BE
PERFORMED, TRY TO PRESERVE AS
MUCH LEPGHT AS POSSIBLE, GIVE
YOURSELF OPGS AND TREATMENT
BECAUSE YOU NEVER KNOW WHAT
MIGHT HAPPEN DOWN THE ROAD,
DELAY CLOSURE AS LONG AS
POSSIBLE.
STABILIZE FRACTURES, MAKE SURE
YOU HAVE SOFT TISSUE COVERS,
THESE ALL RESULT IN BETTER
CLINICAL OUTCOMES FOR THE
PEASHTS.
AND SO SOME OF THE AREAS THAT
THE D.O.D. HAS BEEN REALLY
INTERESTED IN, AND YOU KNOW MY
SURGICAL COLLEAGUES ARE REALLY
FOCUSED ON AND THE BUOY IS
TRYING TO INVEST IN ARE FIRST
AND FOREMOST ARE OFTIO
INTEGRATION, IT'S A MASSIVE
PROGRAM, THAT COLONEL POTTER
THAT I ALLUDED TO PREVIOUSLY
STARTED IN THESE, HE RUNS THAT
PROGRAM OUT OF WALTER REED, BUT
THE IDEA HERE IS TO TRY TO
CIRCUMVENT SOME OF THE
TRADITIONAL ISSUES ASSOCIATED
WITH PROSTHETIC WARE, AND BY
DIRECTLY ATTACHING THE
PROSTHETIC TO THE SKELETON CAN
THERE'S A NUMBER OF BENEFITS
THAT COME ALONG WITH THAT
SURGERY, FROM YOU KNOW AND JUST
INCREASE MOBILITY AND NOT HAVING
TO DEAL WITH DAUNTING OF A
PROSTHETIC, PATIENTS ARE UP AND
MOBILE MORE OFTEN.
A COUPLE OF COMPLIMENTARY
APPROACHES HERE ARE TARGETED
MUSCLE REINNERVATION ASK
REGENERATIVE PERIPHERAL NERVE
INTERFACE AND THESE ARE 2
APPROACHES THAT KIND OF GOT
THEIR START IN TERMS OF TRYING
TO COMMUNICATE WITH MYOELECTRIC
PROSTHESIS, BUT THEY ACTUALLY
FOUND ANOTHER APPLICATION AND
THE TREATMENT OF NEUROMA, SO
WHAT THAT I HAVE BEGUN TO FIND
IS THAT IF YOU GIVE THESE NERVES
SOMETHING TO DO, SOME MUSCLE TO
INNERIVATE, THEN THEY CAN KIND
OF TREAT PAIN USING THESE
APPROACHES, SO THE D.O.D. IS
LOOKING FURTHER INTO THIS AND
TRYING TO, YOU KNOW FIND BETTER
APPLICATIONS FOR THESE TYPES OF
APPROACHES AND THEN FINALLY, THE
COMPOSITE ALOE GRAFT WHICH IS
WHAT IT SOUNDS LIKE IT'S TAKING
CADAVER LIMBS AND THEN
TRANSPLANTING THOSE INTO THE
LOST LIMB OF THE PATIENT AND
RESTORE CERTAIN FUNCTION THROUGH
THOSE PROCEDURES.
OKAY, SO GOING BACK TO THE RED
CIRCLES NOW, WHICH I FIND
INTERESTING, AND CHALLENGING TO
DEFINE.
SO LIMB SALVAGE, WHAT IS LIMB
SALVAGE, CLINICALLY IT'S BONING
AND SOFT TISSUE LOSS WITH INTACT
SENSE BILITY.
THE LITERATURE SUGGESTED NO
DIFFERENCE BETWEEN EMILY SELVAGE
AND AMPUTATION PATIENTS HOWEVER
AS I ALLUDED TO MULTIPLE TIMES
NOW, EPIDEM QUO LOGICAL ANALYSIS
OF THIS POPULATION AND QUITE
FRANKLY JUST IDENTIFYING WHO
THESE PATES ARE IS CHALLENGED BY
AMBIG OW USE DEFINITION BECAUSE
IT VARIES FROM CLINICAL PROVIDER
TO CLINICAL PROVIDER AND IF YOU
ARE TRYING TO ATTACK THIS
PROBLEM ON A LARMING SCALE, YOU
KNOW IT CAN BE VERY TIME
SENSITIVE AND REQUIRES INTENSIVE
CHART REVIEW OR IT CAN RESULT IN
BIASED RESULTS IF YOU ONLY LOOK
AT A SUBSET OF THAT POPULATION.
SO TO TACKLE THAT PROBLEM, IN
COLLEAGUES AND I DEVELOP A DATA
DRIVEN APPROACH TO IDENTIFY
THESE COHORTS, AND THERE'S A
COUPLE PAPERS THAT HAVE BEEN
RECENTLY PUBLISHED BUT IN SHORT
WHAT WE DID IS WE TOOK A
SURROGATE POPULATION SO WE SAID
HOW--WHERE ARE SOME LIMB SALVAGE
PATIENTS THAT WE CAN ADENTIFY
AND WE'RE CONFIDENT OF.
AND THE REALITY IS THAT ANYONE
WHO HAS RECEIVED A SECONDARY
AMPUTATION FOLLOWING A TRAUMA IS
BY A DEFACTOR LIMB SALVAGE
PATIENT SO WE WENT IN THERE AND
IDENTIFIED ICD9 DIAGNOSE AND
PROCEDURE CODES THAT WERE
DISPARATELY ASSOCIATE WIDE THIS
POPULATION AND THEN WE APPLIED
THEM TO A BROADER EXTREMITY AND
TRAUMA POPULATION TO PULL OUT
THOSE PATIENTS THAT MAYBE YOU'RE
SLIPPING THROUGH THE CRACKS AND
ARE NOT EASILY IDENTIFIABLE FROM
AN EPIDEMIOLOGICAL STANDPOINT.
SO I'M NOT GOING TO GET BOGGED
DOWN TO THE LEADS OF THE
DEMOGRAPHICS OF THE POPULATIONS
BUT EFFECTIVELY I WOULD RATHER
SHOW YOU NEW RESULTS THERE THAT
ARE UNPUBLISHED AT THIS POINT
LOOKING AT THAT LIMB SALVAGE
POPULATION AND COMPARING TO A
COUPLE DIFFERENT POPULATIONS
WITHIN MHS WHICH IS OUR PRIMARY
ACHUTATION POPULATION AND THE
NONTHREATENNED LIMB TRAUMA, SO
STILL SEVERE EXTREMITY LIMB
TRAUMA BUT THE LIMB WAS NEVER
REALLY THREATENED, IT DIDN'T FIT
THE CLASSICAL DEFINITION OF LIMB
SALVAGE.
AND SO, FIRST FINDING WE LOOK AT
INJURY SEVERITY AND WE FOUND
WHAT WE EXPECTED TO FIND AND
THAT IS THAT LIMB SALVAGE IS NOT
MUCH DIFFERENT IN TERMS OF
INJURY SEVERITY FROM
NONTHREATENNED LIMB TRAUMA AND
THUS THE AMBIGUOUS NATURE OF
LIMB SALVAGE KIND OF SHOWED ITS
HERE.
OBVIOUSLY, WE ALSO SAW THAT THE
PRIMARY AMPUTEES WERE MORE
SEVERELY INJURED THAT THE LIMB
SALVAGE AND IT FITS MORE
HISTORICAL TO THAT WHEN IT COMES
TO LIMB SALVAGE.
MOVING ON TO SECONDARY HEALTH
EFFECTS, SO WE LOOKED AT THESE
POPULATIONS AND WE FOUND 3 AREAS
THAT KIND OF STUCK OUT TO US IN
THE LIMB SALVAGE POPULATION
RELATIVE TO PRIMARY AMPUTEES AND
NON, SO THE FIRST IS PAIN, OUR
PRIMARY AMPUTEES EXPERIENCED A
LOT MORE JUST NONSPECIFIC PAIN,
SO JUST I HURT EFFECTIVELY, BUT
IF YOU HONE IN ON LIKE A
SPECIFIC AREA, LIKE JOINT PAIN,
WE'VE ACTUALLY FOUND THAT THE
LIMB SALVAGE POPULATION
EXPERIENCES MORE YOINT PAIN THAN
OUR PRIMARY AMPUTEES WHICH WAS A
BIT UNEXPECTED FROM OUR
STANDPOINT.
THE OTHER AREA THAT WE NOTICED
WAS OSTEOARTHRITIS AND LATE
EFFECTS OF MUSKUE LO SKELETAL
INJURIES.
SO THIS WAS HIGHER THAN OUR
AMPUTEE POPULATIONS AND ALSO
RELATIVE TO THE SIMILARLY
INJURED NONTHREATENNED LIMB
TRAUMA GROUP.
SO THERE'S SOMETHING GOING ON
HERE IN TERMS OF THE NATURE OF
THESE YOURS THAT IS RESULTING IN
MORE OSTEOARTHRITIS AND WE FIND
ALSO IF YOU GIVING--YOU FURCATE
OUR LIMB SALVAGE POPULATION
BASED ON WHETHER OR NOT THEY
ULTIMATELY GO ON TO A SECONDARY
AMPUTATION, IT'S EVEN HIGHENER
THOSE THAT ULTIMATELY ELECT TO
HAVE A SECONDARY AMPUTATION.
THE LATE EFFECT MUSK LO SKELETAL
INJURIES THAT MAKES SENSE, TOO,
THAT THOSE ARE HIGH IN THE LIMB
SALVAGE COHORT SET, THAT TRIES
TO CAPTURE MUSCLE ATROPHY
FIBROSIS, THOSE TYPES OF THINGS
THAT ARE TYPICALLY ASSOCIATE
WIDE A RETAINED LIMB THAT
UNDERGOES A SEVERE INJURY LIKE
THIS.
AND THEN FINALLY MENTAL HEALTH,
THE PREVALENCE OF MELGT AT
HEALTH DISORDERS IS HIGH IN ALL
OF OUR POPULATIONS, AND WE ALSO
FOUND THAT YOU KNOW THE
PRIMARIASMUE TEES WHO TYPICALLY
HAVE A COMMUNITY OF RESOURCES
AND ACCESS TO MENTAL HEALTH,
TREATMENT, IT KIND OF MIRRORS
THAT OF OUR LIMB SALVATION THAT
ULTIMATELY ENDS UP ELECTING OR
YOU KNOW BEING TREATED WITH
SECONDARY MEDICATION EMPLOY SO
NOW WE WANT TO LOOK AT CLINIC
UTILIZATIONS.
SO WHAT ARE THERE IN-PATIENT
STATES LIKE EFFECTIVELY?
SO WHAT WE SEE HERE IS THAT OUR
PRIMARY AMPUTEES HAVE THE
HIGHEST LEVEL OF IN-PATIENT BED
AT AS RELATIVE TO LIMB SALVAGE
BUT IF YOU BIFURCATE LIMB
SALVAGE OUT, THOSE THAT GO ON TO
SECONDARY AMPUTATION GO UP AND
MATCH THE PRIMARY, SO THEY'RE IN
THE HOSPITAL FOR A LONG TIME,
UNDERGOING A NUMBER OF
PROCEDURES, AND IT'S
JUST--THERE'S AN OPPORTUNITY
THERE FOR BETTER CARE AND WE
NEED TO FURTHER RESEARCH THIS
POPULATION TO SEE IF WE CAN
IMPROVE THEIR OUTCOMES
EFFECTIVELY IS WHAT WE'RE TRYING
TO SHOW HERE.
NEXT UP, WE'RE LOOKING AT
OUTPATIENT CLINIC ENGAGE AM, SO
THIS IS THE NUMBER OF TIMES
THAT--THE FREQUENCY OF WHICH
PATIENTS FROM OUR VARIOUS GROUPS
ENGAGE WITH A CLINIC AT LEAST
ONCE.
SO DID YOU WALK IN THE DOORS AT
ALL?
SO WHAT WE SEE HERE IS THAT OUR
PTN, ORTHOPEDIC CLINICS ARE HIGH
ACROSS THE BOARD BUT THERE'S
DISPROPORTIONATE ENGAGEMENT
ACROSS THE COHORTS AND IF YOU
LOOK AT ENGAGE WANT RATES OF THE
CLINICS, EVERYTHING EXCEPT FOR
ORTHOPEDIC PSYCHIATRY, MENTAL
HEALTH AND PSYCHIATRY IS HIGHER
THAN FOR OUR LIMB PATIENTS THAN
OUR FOR OUR LIMB SALVAGE
PATIENTS.
SO YOU LOOK AT WHAT I MENTIONED.
WHAT DID THAT LEAVE?
THAT'S OCCUPATIONAL THERAPY,
PHYSICAL MEDICINE, THAT'S
NEUROLOGY, THESE PEOPLE ARE NOT
BEING SEEN AT THE SAME RATE OR
AT THE SAME FREQUENCY AS THEIR
PEERS IN THE PRIMARY AMPUTEE.
WE DON'T KNOW WHY THAT IS.
WE DON'T KNOW IF IT'S THE
PIER-COMMUNITY ASPECT THAT TENDS
TO DEVELOP AROUND THE AMPUTEE
POPULATION RELATIVE TO LIMB
SALVAGE POPULATION BUT IT'S
THERE IT DESERVES FURTHER
ATTENTION EFFECTIVELY.
SO THAT WAS ENGAGEMENT.
THIS IS UTILIZE SO NOT ONLY DID
THEY WALK IN THE DOOR BUT HOW
MANY TIMES DID THEY COME BACK TO
THE CLINIC EMPLOY SO HOW HIGHEST
VOLUME ACROSS THE COHORTS WAS
SEEN IN THE PT AND OT CLINICS
AND FOR THOSE THAT GO ON TO A
SECONDARY AMPUTATION FROM OUR
LIMB SALVAGE GROUP, WE SEE THEY
VISIT ALL THE CLIPPICS MORE THAN
THEIR PEERS THAT DO NOT
ULTIMATELY RECEIVE AN
AMPUTATION, WE DON'T KNOW IF
THAT'S CAUSE AND EFFECT ISSUE
BUT THAT XIFS AND 1 WE'RE WE'RE
LOOKING INTO THIS FURTHER TO
VIEW THAT IS LIKE ONCE THEY
RECEIVE THEIR AMPUTATION, ALL OF
A SUDDEN DO THEY START BEING
SCENE IN THESE CLINICS MORE
OFTEN BECAUSE THEY RECEIVE THEIR
AMPUTATION SORE IS IT RELATED
MORE TO THE SEVERITY OF THEIR
INJURY?
AND THAT'S JUST SOMETHING WE
HAVE TO DIG FURRINGER INTO AND
WE HAVEN'T GOTTEN THAT FAR INTO
THE DATA YET.
SO WE WILL LOOK AT 1 PARTICULAR
INJURY PATTERN THAT I'M
INTERESTED IN, WITHIN THAT
SUBSET OF LIMB SALVAGE IS THAT
IS VOLUMEETIC MUSCLE LOSS,
VOLUMETRIC MUSCLE LOSS WAS
FORMALLY DEFEIGNED, IT'S BEEN
AROUND FOREVER AS LONG AS THERE
HAS BEEN COMBAT EFFECTIVELY, BUT
IT WAS KIND OF FORMALLY
DEFEIGNED IN 2011 SO WE'VE BEEN
STUDYING THIS FOR JUST OVER 10
YEARS NOW BUT IT'S THE TRAUMATIC
OR SURGICAL LOSS OF SKELETAL
MUSCLE THAT RESULS IN A CHRONIC
FUNCTIONAL DEFICIT.
IT IS LIMITED IN TERMS OF
CLINICAL TREATMENT OPTIONS SO
THERE IS NO SURNLICAL STANDARD
OF CARE FOR VOLUNTEERS UMKCET
RICK MUSCLE LOSS.
REHABILITATION IS COMMONLY THE
ONLY TREATMENT THAT GIVEN BUT
IT'S OFTEN CHALLENGED BY THE
FACT THAT IT'S, THE PATHOBIOLOGY
OF VML IS DIFFICULT, SO THE
AMOUNT OF HEALTHY TISSUE THERE
TO BE USED IS GONE.
SO WE USE THIS AS AN OPPORTUNITY
FOR BIOENGINEERING SOLUTIONS TO
TRY TO REGENERATE SOME OF THIS
MUSCLE AND HOPEFULLY IMPROVE THE
OUTCOMES OF THESE PATIENTS.
SO THIS IS AN EFFORT THAT 1 OF
THE POST DOCS FROM OUR GROUP LED
AND WE WANTED TO TAKE A ELECTRIC
AT THE LITERATURE AROUND VML.
SO IT'S BEEN OVER 10 YEARS WE'VE
BEEN DOING THIS, WHAT KIND OF
PROGRESS HAVE WE MADE?
SO IF WE LOOK AT THE FIELD AS A
WHOLE WE SEE EXPOTENTIAL GROWTH
IF PUBLICATIONS SO THERE'S BEEN
INCREASED INTEREST IN THIS FIELD
AND IN THIS PROBLEM, IN GENERAL,
THE PUBLICATIONS IN THE FIELD OF
VML ARE CITED AT A HIGHER RATE
THAN THOSE OF OTHER
BIOENGINEERING FIELDS THAT THIS
DATA WAS PULLED FROM THE
[INDISCERNIBLE] TOOL PROVIDED BY
NIH.
PREDOMINANTLY THE STUDIES ARE
DONE IN ANIMAL MODELS, THEY'RE
IN VIVO IN NATURE SIMPLY BECAUSE
IT'S HARD TO RECAPITULATE THE
PATHOBIOLOGY OF THESE YOURS IN
YOU KNOW CELL OR TISSUE BASED
MODELS.
AND THEN OBVIOUSLY HUMAN
CLINICAL TRIALS ARE EXPENSIVE
ANDY DON'T KNOW A LOT ABOUT THE
YOUR SO WE'RE NOT GOING TO JUMP
STRAIGHT INTO HUMANS.
O THERE WERE SOME CLINICAL
TRIALS BUT PREDOMINANTLY THESE
HAVE BEEN FOCUSED ON ANIMAL
MODELS, BOTH SMALL AND LARNG
ANIMAL MODELS AND THEN OVER TIME
WE'VE ALSO SEEN THIS GROWTH IN
PATENT APPLICATIONS AND PATENTS
ISSUED.
AGAIN LOOKING BROADLY AT THE
FIELD, THIS IS A COLLABORATOR OF
MINE STARTED RISING UP AT THE
UNIVERSITY OF MINNESOTA.
THEY DID A META-ANALYSIS OF THE
LITERATURE THAT HAS BEEN PUB
LESHED IN VML, LOOKING AT THE
EFFICACY OF TREATMENT, SO WHAT
ARE WE DOING?
I ALOUDED TO THE FACT THAT
THERE'S NO SURGICAL STANDARD OF
CARE FOR VML.
SO YOU KNOW, SARAH WANTED TO
LOOK THROUGH THE LITERATURE AND
SEE WHAT WORKS, WHAT DOESN'T
WORK AND WHY, AND THERE ARE SOME
KIND OF THINGS HERE SO THE KEY
FINDINGS FROM THAT STUDY WERE
THAT TREATMENT DOES RESULT IN
SIGNIFICANT I IMPROVEMENT AND
FUNCTIONAL CAPACITY OF MUSCLE
MAY SEEM LIKE KIND OF A--YOU
KNOW AN OBVIOUS ANSWER BUT WHEN
THERE'S NO STANDARD OF CARE,
KNOWING THAT TREATING DOES HELP
AS CORRELATED POSE TO JUST
LETTING THESE INJURIES FIEB
RESOURCES, THAT'S A SIGNIFICANT
FINDING AND THEN SHE ALSO FOUND
THAT THE MOST EFFICACIOUS OF THE
TREATMENTS THAT SRO BEEN TRIED
AND SOME COMBINATION OF AN
ACELLULAR BIOMATERIAL COMBINED
WITH PROGENITOR CELLS STEM
CELLS, MY MYOBLASTS, THE DOWN E
IS THAT THE TREATMENT IS STILL
SMALL, SO ROUGHLY 16%
IMPROVEMENT WHICH MEANS WE HAVE
A WAYS TO GO EFFECTIVELY.
SO BASED ON THAT SMALL EFFECT,
YOU KNOW THE FIELD HAS STARTED
TO THINK ABOUT WAYS TO ENHANCE
THAT EFFECT AND LOOK AT
PERCENTAGES, AND SO, 1 OF THE
WAYS WE'VE DONE THAT WE'VE
SPRENG OFF THAT IS THE CONCEPT
OF REHABILITATION WHICH IS WHAT
YOU MAY BE FURTHERMORE WITH, SO
VML WAS 1 OF THE FIELDS THAT
KIND OF HOPPED ON THE REGION OF
REHAB TRAINED FAIRLY EARLY IN
THE PROCESS, BUT THE IDEA HERE
IS THAT REHABILITATIVE
INTERVENTIONS CAN HAVE DIRECT
BENEFITS FOR THERAPY EMPLOY SO
WE KNOW THAT LOADING CAN IMPACT
STEM CELL FATES IN THE MUSCLE,
AS WELL AS OTHER MUSK LO
SKELETAL TISSUES, HOWEVER THE
PROGRESS IN THIS FIELD HAS BEEN
HAMPERED BY THE REGENERATIVE
THERAPIES HAVE NOT BEEN
EFFECTIVE ENOUGH AND SO, LOOKING
FOR SYNERGYS BEFORE YOU HAVE A
THERAPY THAT IS EFFECTIVE ON ITS
OWN, CAN BE KIND OF CHALLENGING.
ONE THINK THIS I WILL SAY THAT
WE FOUND THUS FAR IN THE FIELD
IS THAT TIME TO INITIATION OF A
REHAB THERAPY FOR THE VML WILL
BE A KEY VARIABLE TO SUCCESS
EMPLOY AT LEAST THAT'S MY
INITIAL INCLINATION, AND YOU
KNOW EARLY REPORTS FROM STUDIES
OUT OF MY GROUP AND OTHERS
SUGGEST THAT EARLY INITIATION OF
REHAB WILL BE DELETERIOUS TO
REGENERATIVE OUTCOMES.
OKAY, SO NOW, I'M GOING TO SHIFT
THE FOCUS TOWARDS KIND OF THE
FUTURE REQUIREMENTS THAT THE
D.O.D. IS KIND OF SENDING DOWN
OUR WAY AS WE MOVE FORWARD AND
THATTA AS WE LOOK FORWARD TO THE
NEXT CONFLICT.
SO PROJECTIONS FOR THE NEXT
CONFLICT, THE BATTLEFIELD WILL
BE MULTINATURAL, LAND, SEE,
SPACE, ALL OF THE ABOVE AND THE
PROJECTIONS ARE ALSO THAT WE'RE
NONAPOPTOTIC LONGER GOING TO
HAVE SUPERIORITY IN TERMS OF AIR
OR ARMS RELATIVE TO THE
ADVERSARY SO WE'RE TALKING ABOUT
NEAR PEER ADVERSE SARYS, THEY'RE
VERY SOPHISTICATE INDEED THEIR
TECHNOLOGIES AND SO WHAT DOES
THAT FUTURE CONFLICT GOING TO
ELECTRIC LIKE AND HOW CAN WE BE
PREPARED FOR IT?
SO PERSPECTIVE, SO THE WHYED
FROM THAT IS THAT YOU KNOW OUR
INJURED SERVICE MEMBERS WILL BE
EFFECTIVELY LEFT TO FEND THR
THEMSELVES IN THE BATTLEFIELD
THAN THEY WERE IN THE PAST.
SO IF I GO BACK ACTUALLY DURING
THE CONFLICTS IN AFGHANISTAN AND
IRAQ, THERE WAS A POLICY KNOWN
AS THE GOLDEN HOUR WHICH WAS
WITHIN AN HOUR OF INJURY, AN
INJURED SERVICE MEMBER WOULD BE
EVACUATED TO A HIGHER LEVEL CARE
FACILITY AND THEY WOULD BE SEEN
BY A SURGEON WITHIN 60 MINUTES
OF INJURY, MOVING FORWARD, THEY
DO NOT PROJECT THAT WILL BE THE
CASE AND SPECIAL PROJECTIONS
SUGGEST THEY MAY NOT BE ABLE TO
MED VAC AN INJURED SERVICE
MEMBER FOR ANYWHERE UP TO 2
WEEKS, SO THAT'S A LONG TIME TO
BE SUFFERING WITH AN INJURY IS
NOT HAVE HIGH LEVEL MEDICAL
CARE.
SO AS WE STARTED TO THINK ABOUT
THIS WE KIND OF PUT THIS
PERSPECTIVE PIECE ON HOW TO YOU
KNOW MANAGE THESE TYPES OF YOURS
FROM A BIOLOGICAL STANDPOINT.
SO, WHAT--WHAT ARE GOING TO BE
THE DESIGN CRITERIA THAT ARE
NECESSARY FOR BIOLOGICALLY
FOCUSED TECHNOLOGY TO TRY TO
STABILIZE THAT INJURY, AND/OR
BEGIN TREATING THAT INJURY ON
THE BATTLEFIELD BY A COMBAT
MEDIC THAT CAN YOU KNOW PREVENT
DELETEEROUS OUTCOMES EFFECTIVELY
SO THAT WHEN THEY DO REACH A
HIGHER LEVEL OF CARE, THEY'RE IN
THE BEST POSITION POSSIBLE TO
HAVE A POSITIVE OUTCOME OF
SURGERY OR WHAT HAVE YOU EMPLOY
SO WE PUT TOGETHER THIS
PERSPECTIVE PAPER WHICH WAS
PUBLISHED 2 YEARS AGO AT THIS
POINT ON KIND OF WHAT DO WE
NEED.
THE MATERIALS WILL NEED TO BE
SELF-ADMINISTERRABLE, SIMPLE TO
USE, LIGHT WEIGHT, SHELF STABLE,
MINIMAL OR 0 ELECTRICAL
REQUIREMENTS, AND IDEALLY THEY
WOULD HAVE SOME BENEFIT TO
RESTORING FUNCTION OR OTHERWISE
SLOWING THE DETERIORATION OF
THAT LIMB.
SO JUST TO HIGHLIGHT A PIRP FROM
OUR GROUP, THIS IS HIGHLIGHTING
TRYING TO COMPLISH THOSE GOALS.
SO WHAT WE DID HERE IS TRY TO
DEVELOP AN INSITU FORMING MUSCLE
VOID FILLERS SO THE IDEA HERE IS
THAT YOU INRECYCLING THIS
MATERIAL INTO THE WOUND, AND IT
WILL STABILIZE THAT SPACE, IT
WILL SIT THERE FOR UP TO 4
WEEKS, IT'LL PREVENT FIBROTIC
INFILTRATION, IT HAS A MINIMAL
HOST RESPONSE SO WE'RE TRYING TO
MINIMIZE DELETERIOUS OUTCOMES
HERE, THIS WAS JUST OUR FIRST
FORAY INTO THIS FUTURE EFFORTS
ARE CURRENTLY ONGOING TO ADD
BIOACTIVE PAY LOADS THAT MIGHT
BE ABLE TO RELEASE ANTIFIBROTICS
OR ANTIBIOTICS, OTHER THINGS
THAT WOULD TRY TO STABILIZE THAT
WOUND ENVIRONMENT.
AND THEN WE'RE ALSO MOVING IT UP
TO LARGER ANIMAL STUDIES AS
WELL.
WE WILL BE TRAVELING UP TO
INDIANA UNIVERSITY TO WORK WITH
SOME OF OUR COLLEAGUES FROM THE
SCHOOL OF MEDICINE THERE TO PUT
THESE INTO A PIG MODEL IN
JANUARY EMPLOY SO WITH THAT WANT
TO LEAVE WUFINAL IMPRESSIONS AND
PINS PAL INSIGHTS HERE.
SO AFTER THE LAST 2 DECADES THE
D.O.D. AND OUR SILLIVIAN
PARTNERS HAVE MADE TREAMENDOUS
ADVANCEMENTS IN THE TERMS OF
CARE, METHODS AND TECHNOLOGIES
WHICH HAS DELIVERED AN
UNPRECEDENTED LEVEL OF FUNCTION
AND QUALITY OF LIFE FOR OUR
SERVICE MEMBERS IN TERMS OF
AREAS FOR CONTINUED IMPROVEMENT
AND ENGAGEMENT FROM OUR CIVILIAN
PARTNERS, IS WE NEED A CONTINUE
GENERATING HIGHER LEVELS OF
CONCEPTS, SO FAIRLY NEW
CONACCEPTS.
WE NEED TO FIND FUNDING FOR
CLINICAL TRIAL ANDS THAT SORT OF
THING TO FURTHER THAT FIELD.
WE NEED TO PUSH HARDER INTO
TECHNOLOGIES FOR PROLONGED CARE
TO PREPARE US FOR THAT FUTURE
BATTLEFIELD AND ALL THESE AREAS
ARE GOING TO BENEFIT FROM
INTERDISCIPLINARY MULTISECTOR
COLLABORATIONS, ACADEMIA,
INDUSTRY AND FEDERAL.
AND THEN FINALLY, FROM MY
PERSPECTIVE AS A FAIRLY NEW
FACULTY MEMBER, TRAINING
OPPORTUNITIES AND FOSTERING THE
NEXT GENERATION OF SCIENTISTS TO
WORK ACROSS THESE VARIOUS FIELDS
TO ENGAGE REHAB COLLEAGUES LIKE
YOU ALL WITH ENGINEERS AND BASIC
CELL BIOLOGISTS, I THINK THAT'S
WHERE WE'RE REALLY GOING TO SEE
INNOVATION MOVING FORWARD.
AND I THINK THAT WE NEED TO BE
FACILITATING WAYS FOR A CELL
BIOLOGIST FROM MY LAB TO GO
SPEND SOME TIME IN A PHYSICAL
MEDICINE LAB SOMEWHERE AND TO
LEARN ABOUT REHAB.
SO WITH THAT I WILL THANK YOU
FOR YOUR TIME AND OPEN UP THE
FLOOR FOR QUESTIONS.
>> THANK YOU SO MUCH.
WE'RE OPEN TO QUESTIONS.
BOB IN.
>> THANK YOU VERY MUCH.
THAT WAS FASCINATING.
WHEN YOU SHOWED THE SEQUEL I FOR
VARIOUS MEASURES SUCH AS PAIN
WHEN YOU COMPARED PRIMARY
AMPUTATION TO LIMB SALVAGE, WAS
THAT FOR LOWER EXTREMITY ALONE
OR DO YOU SEE DIFFERENCES
BETWEEN UPPER AND LOWER FOR
THOSE COMPARISONS?
>> YEAH, SO I SHOULD HAVE
CLARIFIED THAT, ALL WORK TO DATE
HAS BEEN DONE ON THE LOWER
EXTREMITIES, AND THE REASON FOR
THAT IS BECAUSE WE USE THIS DATA
DRIVEN APPROACH.
WE HAVE A LOT MORE LOWER
EXTREMITY TRAUMA PATIENTS AND SO
THE NUMBERS ARE JUST TOO SMALL
TO ROLELY PULL OUT THOSE CODES
IN THE SAME WAY FOR THE UPPER
EXTREMITY SO IT WAS VERY MUCH
FOCUSED LOWER EXTREMITY ONLY.
>> FRANCISCO, THEN LEWIS?
>> YES, GOOD MORNING, THANK YOU
FOR GREAT INSIGHT INTO THIS
DR. GOLDMAN.
SO ABOUT BIOMETRIC BONE LOSS I
WAS VERY IMPRESSED WITH YOUR
ABILITY TO START MOVING IN THAT
PARTICULAR DIRECTION, SO MY
QUESTION IS REALLY ABOUT THE
FUNCTION OF THAT MUSCLE TISSUE
THAT IS BEING REGENERATED.
FOR EXAMPLE, ARE YOU CONSIDERING
MOTOR END PLATES, WOULD IT BE
FUNCTIONAL MUSCLE BECAUSE I HAVE
SOME IDEAS, SUGGESTIONS, ET
CETERA ABOUT HOW TO MAKE THAT
FUNCTIONING MUSCLE TISSUE THAT'S
ORGANIZED AND INNERIVATED AND SO
ON.
>> YEAH, SO MOTOR
[INDISCERNIBLE] AND
NEUROMUSCULAR JUNCTIONS THAT'S
DEFINITELY AN AREA THAT'S BEING
LOOKED AT MORE--UNDER MORE
SCRUTINY NOW.
YOU KNOW EARLY ON IN THE FIELD
PEOPLE WERE JUST TRYING TO GET
ABOUT SORT OF OUTCOME AND THE
ANSWER TO YOUR QUESTION IS I
BELIEVE, MOST OF THE REGENERATED
MUSCLE IS FUNCTIONAL.
THE PROBLEM HOWEVER IS THE
QUANTITY THAT IS ACTUALLY
REGENERATED AND THE EFFICIENCY
OF REINNERVATION.
I THINK THERE'S SOMETHING LOST
THERE IN TERMS OF RECRUITMENT,
MUSCLE FIBER RECRUITMENT AND YOU
KNOW OPTIMIZING THOSE
NEUROMUSCULAR JUNCTIONS IN THE
REGENERATIVE TISSUE.
THE OTHER PROBLEM, THERE IS, YOU
KNOW THERE'S STILL SOME FIBROTIC
DEPOSITION, WITH ALL THE
TREATMENTS THAT HAVE BEEN TRIED
EFFECTIVELY, SO THERE'S TILL
ISSUES WITH, YOU KNOW LOSS OF
ARCHITECTURE, SUBOPTIMAL
ALIGNMENT OF MUSCLE FIBERS THAT
WERE REGENERATED SO IT'S A
MULTIFACTORIAL PROBLEM.
THERE'S SOME MITOCHONDRIAL
DYSFUNCTION AS WELL, SO THERE'S
NUMEROUS TARGETS TO GO AFTER.
BUT APPROXIMATE YOU DO HAVE
IDEAS ON MOTOR INPLATES FEEL
FREE TO REACH OUT AFTERWARDS,
WOULD BE HAPPY TO TALK IN MORE
DEPTH.
>> THANK YOU.
>> LEWIS?
>> GOOD MORNING.
THANKS FOR A REALLY
[INDISCERNIBLE], I REALLY
ENJOYED THAT QUITE A BIT.
AS SOMEBODY WHO DOES A LOT OF
UPPER LIMB AMPUTATION, RESEARCH,
MORE PRACTICES A NEURAL REHAB
POINT OF VIEW, I AM ALWAYS
REALLY CURIOUS ABOUT HOW SOME OF
THE THINGS YOU TALKED ABOUT
REALLY CAN BE INTEGRATED MORE
INTO OUR KNOWLEDGE OF NEURAL
RECOVERY AFTER AMPUTATION, RIGHT
AND PROSTHESIS USAGE AND I'VE
ALWAYS BEEN CURIOUS ABOUT WAYS
IN WHICH WE CAN KIND OF DO WHAT
YOU WERE SORT OF TALKING ABOUT
IN THERE, OF BETTER CONNECTING
SOME OF THE WORK THAT YOU KNOW I
DO MORE SPECIFICALLY IN
NEUROREHAB AND HUMAN POPULATIONS
AND ALL THAT STUFF, WITH SOME OF
THESE REALLY EXCITING NEW
FRONTIERS, I THINK KIND OF
COMING FROM A CELL PHYSIOLOGY
AND YOU KNOW MOTOR, YOU KNOW
REGENERATIVE MUSCLE POINT OF
VIEW, I THINK ABOUT WAYS IN
WHICH THAT CAN ACTUALLY HAPPEN,
WAYS IN WHICH WE CAN BROADEN
CONVERSATIONS, WAYS IN WHICH
LIKE YOU SAID, THE MILITARY AND
VA SYSTEMS CAN WORK BETTER WITH
PEOPLE LIKE ME, GEORGIA TECH,
THAT'S NOT IN THAT SYSTEM, I WAS
JUST REALLY INSPIRED BY THE ALL
THINGS YOU WERE TALKING ABOUT, I
THINK THERE'S A HUGE OPPORTUNITY
FOR STRONGER COLLABORATIONS, SO
THAT WE'RE KIND OF WORKING
ALTOGETHER, AND WORKING IN
PARALLEL.
>> YEAH, I AGREE.
I FEEL LIKE A LOT OF PEOPLE
CHEER LEAD COLLABORATION BUT
WHEN IT'S TIME TO HAVE THE
RUBBER HIT THE ROAD, THERE'S
ALWAYS CHALLENGES.
AND SO, I DON'T KNOW WHAT THE
ANSWER THERE IS, YOU KNOW I
WOULD CHALLENGE, YOU KNOW THE
FOLKS WITHIN THE D.O.D., THE
FOLKS AT NIH, THOSE THAT LEAD
OUR PROFESSIONAL SOCIETIES TO
TRY TO YOU KNOW PROVIDE THE
PLATFORMS FOR FOLKS TO MEET,
INVITE SPECIFIC SPEAKERS WITH
THE IPT GREATER TENSION OF
HAVING THESE INTERDISCIPLINARY
PANELS AT EVENTS, THAT'S REALLY
THE ONLY WAY IT'S GOING TO
HAPPEN, THAT IS JUST COLD
CALLING SOME FOLKS AND REACHING
OUT AND YOU KNOW ASKING.
I DO THAT MORE THAN I SHOULD,
PROBABLY.
>> YEAH, I APPRECIATE THE SHOUT
OUT TO REGENERATIVE
REHABILATION, AND IN 1 OF OUR
NETWORKS WE HEARD RICK SEEINGLE
HIGHLIGHT THAT'S 1 OF OUR, SO
I'M DPLAD THAT CONNECTION'S
THERE.
I WANT TO PUSH MORE ON WHAT
LEWIS WAS SAYING, I WAS THINKING
THE SAME THING, WHO ACTUALLY IS
DOING THE SURMRY, THE AMPUTATION
AND ARE THEY THINKING AHEAD TO
THE FACT THAT PEOPLE LEAK LEWIS
WILL BE TRYING TO PUT WHOLE
NERVE SIGNALS THERE AND YOU
MENTIONED ABOUT PAIN AND TO WHAT
EXTENT CAN PLANNING OUT THAT
SURGERY PREVENT NEUROMAS AND
PREVENT--DOES IT MAKE SENSE TO
PREVENT THE PAIN BY PLANNING THE
SURMRY MORE CAREFULLY.
>> YEAH, SO I WOULD SAY THAT IS
SOMETHING THAT I HAVE SEEN A FEW
VERY THOUGHTFUL SURGEONS START
TO DO MORE AND MORE OVER MY
TENURE AT WALTER REED WHICH HAS
BEEN 6 YEARS NOW, BUT YEAH,
FOLKS LIKE COLNET POTTER WHO I
A--COLNET --COLONEL POTTER, HE'S
AN ORTHOPEDIC SURGEON BUT WHEN I
ALLUDED TO HIS IDEAS OF HOW TO
DO A GOOD AMPUTATION, IT'S ALL
ABOUT BEING THOUGHTFUL.
THINKING ABOUT NOT JUST AN
AMPUTATION BUT ABOUT LIMB
OPTIMIZATION, SO LOOKING FORWARD
TO THE OUTCOMES, PREPARING THAT
LIMB TO RECEIVE A PROSTHESIS
WHETHER IT'S AN OFTIO GENERATED
PROSTHESIS OR A TRADITIONAL
PROSTHESIS, AND HOW TO DO THAT
IN A THOUGHTFUL WAY TO MAXIMIZE
THE OUTCOME FOR THE PATIENT.
AND SO, THINGS LIKE PRESERVING
SOFTTISSUE, PRESERVING AS MUCH
LENGTH AS POSSIBLE, THOUGHTFUL
NERVE MANAGE AM, SOME OF THE TMR
AND RPI, TYPE OF APPROACHES,
THOSE ARE ALL GETTING AT EXACTLY
WHAT YOU'RE TALKING ABOUT WHICH
IS PREVENTING NEUROMA AND TRYING
TO TREAT THOSE THINGS TO YOU
KNOW IMPROVE THE OVERALL QUALITY
OF LIFE OF THE PATIENT.
>> [INDISCERNIBLE]
>> SORRY.
YEAH.
NLAST QUESTION.
>> THANK YOU, SO WITH THE GOLDEN
HOUR BEING EXTENDED TO 2 WEEKS
WE NEED TO CARRY A LITTLE MORE
EQUIPMENT AND RESOURCE AND THEN
THIS TERMS OF TECHNOLOGY
FACILITATION OF WHAT'S IN THE
PIPELINE, WITH THE SMART GARMINS
OR BIOPNEUMATIC SYSTEMS, YOU
KNOW HOW DO YOU COPE WITH THAT
IN.
>> WE'RE STILL PRETTY YOUNG IN
THAT FIELD AND SO THE ANSWER IS
NO, YOU'RE FOCUS ON THE GOING TO
BE ABLE TO CARRY MORE AND MORE
EQUIPMENT JUST PHYSICAL
LIMITATIONS OF THE SERVICE
MEMBER.
SO THAT'S KIND OF WHY WE PUT
FORTH THOSE DESIGN CRITERIA,
LIKE THINGS NEED TO BE
REPURPOSABLE OR VERY LIGHT
WEIGHT AND RUGGED AND SO LIKE IF
YOU PUT SOMETHING IN A PACK,
SOMETHING ELSE IS GOING TO HAVE
TO COME OUT.
AND SO THAT'S A MAJOR TRADE-OFF
AND THERE'S BEEN A OF EFFORTS
ONGOING, SOME OF THE STUFF I
DIDN'T EVEN TOUCH ON FROM 1 OF
MY COLLEAGUES AT THE CFI IN SAN
ANTONIO, THEY'RE WORKING ON
NOVEL EXOSKELETON SOLUTIONS TO
RYE THAT CAN BE APPLIED IN THE
FIELD TO TRY TO GET THAT SERVICE
MEMBER UP AND RUNNING TO EITHER
GET OUT OF HARM'S WAY OR YOU
KNOW ALLOW THEM TO FIGHT BACK.
SO WE HAVE THOUGHTS AS WELL ON
HOW TO INTEGRATE THAT WITH
BIOLOGICAL HEALING AND PREPPING
THE WOUND TO HAVE A BETTER
SURGICAL AND ULTIMATELY
FUNCTIONAL OUTCOME.
BUT, IT'S GOING TO BE A
CHALLENGE AND THAT'S GOING TO BE
A HOT AREA FOR TWEPMENT FOR
YEARS TO COME IN MY MIND.
>> THANK YOU DR. GOLDMAN, MUCH
APPRECIATED.
I THINK WE WILL MOVE ON TO THE
NEXT SPEAKER.
DR. P A LMIER-SMITH AND ARE WE
SET UP ONLINE IN?
>> I THINK SO.
GOOD MORNING, CAN EVERYONE HEAR
ME?
>> YES.
>> LET'S SEE IF WE CAN SHARE THE
SCREEN AND EVERYTHING GOES
SMOOTHLY HERE.
LET ME START PRESENTATION MODE
AND SEE WHERE WE GO.
YOU WILL SEE NOTE SLIDES WHICH
WE DON'T WANT YOU TO SEE, RIGHT?
SEE IF I SWITCH THIS ON MY KREEN
HERE?
ARE YOU SEEING NOTE SLIDES OR
REGULAR?
>> REGULAR.
>> GREAT.
GOOD MORNING, THANKS FOR HAVING
ME HERE, I'M A PROFESSOR IN THE
SCHOOL OF KINESIOLOGY AND
DEPARTMENT OF ORTHOPEDIC SURGERY
AT THE UNIVERSITY OF MICHIGAN
AND I WAS GIVEN THE TASK OF
TALKING TO YOU ABOUT SPORTS
YOURS WHICH IS QUITE COMPLICATED
TO DO IF 20 MINUTES TIME SO KNOW
IT'S GOING TO BE BROAD AND I AM
HAPPY TO TAKE DETAILED QUESTIONS
YOU HAVE AS WE MOVE FORWARD.
SO I THOUGHT WE WOULD START OFF
BY TALKING ABOUT SPORT AND WHERE
WE SHOULD BE DOING IT AND THEN
SOME OF THE CONSEQUENCES THAT
HAPPEN WITH IT AND SO, IF YOU
JUST LOOK AT KIDS THERE'S OVER
46 MILLION CHILDREN THAT
PARTICIPATE IN SPORTS ANNUALLY
AND WE WANT TO THEM TO
PARTICIPATE IN SPORTS BA UNITED
STATES IT PROVIDES A LIFETIME OF
BENEFIT.
AND IF YOU LACK AT THE GRAPHIC,
IF YOU PARTICIPATE IN SPORT, YOU
WILL LESS LIKELY TO BE OBESE,
YOU WILL DO BETTER IN WILL 62,
YOU ARE LESS LIKELY TO ENGAGE IN
RISKY BEHAVIOR, AS AN ADULT THE
CHILDREN THAT PARTICIPATE INDEED
ARK DULTS ARE MORE SUCCESS OF AT
WORK AND THEY ARE REDUCE RISK OF
DISEASE SO WE WANT TO ENCOURAGE
SPORT PARTICIPATION AND IT'S NOT
JUST KIDS THAT ARE PARTICIPATING
IN SPORTS, ABOUT 20% OF THE
WHOLE U.S. POPULATION IS
PARTICIPATE NOTHING SPORES AND
THERE'S BEN FIELD FUNCTIONSES TO
HEALTH, ET CETERA, TO DOING
THAT.
SO WE WANT TO ENCOURAGE THAT,
BUT 1 CONSEQUENCES OF THE BAD
THINGS ABOUT SPORT PARTICIPATION
IS SPORTS OBVIOUSLY CAN LEAD TO
YOUR AND WE JUST LOOK AT KIDS
THAT ARE 18 AND UNDER, THERE'S
ABOUT 8 AND HALF BILLION SPORTS
YOURS THAT ARE OCCURRING EACH
YEAR.
ABOUT EVERY 25-SECONDS A CHILD
IS SEEN IN THE EMERGENCY
DEPARTMENT BECAUSE OF A SPORT
INJURY.
COMMON DIAGNOSIS THAT WE SEE ARE
SPRAIN ANDS TRAINS, CONDUGZS,
FRACTURES, ABRASIONS AND
CONTUSIONS, AND THEN YOUR RATE
WILL VARY BY SPORT AND BY TYPE
OF COMPETITION OR PRACTICE
RESEARCH THAIS YOU'RE IN AND IF
YOU TAKE A LOOK AT THE GRAPHIC
THERE THIS IS IN COLLEGIATE
SPORTS AND SO IT WOULD VARY IF
WE'RE LOOKING AT HIGH SCHOOL OR
RECREATIONAL SPORT BUT HAD IS
LOOKING AT PRACTICE YOUR RATES
VERSUS GAME YOUR RATES ACROSS A
VARIETY OF SPORTS AND IT'S
PRETTY UBIQUITOUS THAT WE
SUSTAIN MORE INJURIES DURING
GAMES THAN AT PRACTICE, THE
PRACTICE IS THE BROWN, THE BLUE
IS THE GAME, CAN YOU SEE THERE'S
MORE INJURIES THAT OCCUR DURING
PRACTICE AND THEN SOME OF THE
SPORTS WITH HIGHER INJURY RATES
WILL BE AMERICAN FOOTBALL,
SOCCER, BASKETBALL, AND HOCKEY
AS WELL AS GYMNASTICS.
BUT IN ALL SPORTS, FOLKS ARE
SUSTAINING INJURY.
I WOULD SAY THE FINANCIAL BURDEN
FROM SPORT INJURY IS NOT WELL
UNDERSTOOD.
MOST OF THE RESEARCH IS DONE
LOOKING AT THE COST FOR
IN-PATIENT HOSPITALIZATION OR
EMERGENCY DEPARTMENT VISITS.
WHEN WE LOCK AT OVERALL
COMBINING ALL OF SPORTS
INJURIES, YOU SEE THE STATISTICS
HERE, ABOUT $133 MILLION
ANNUALLY ARE SPENT ON SPORTS
INJURIES IN-PATIENT
HOSPITALIZATIONS AND THAT'S JUST
IN IEWGHT SPORTS ALONE.
IN A TODAY THAT WAS PRETTY COMP
REHENNIVE JUST DONE IN FLORIDA
WHERE THEY LOOK AT IN-PATIENT
HOSPITALIZEITION AND EMERGENCY
DEDEPARTMENT VISITS THEY SHOWED
THAT $22.3 MILLION IS SPENT ON
SPORT YOURS JUST IN THEIR STATE
AND YOU COULD APPLY THAT ACROSS
AND IT'S NOT CONSIDERING ALL OF
THE CARE THAT IS ROUGH ATOM
VIEDED BY ATHLETIC TRAINERS THAT
ARE AT COOLS OR VISITS TO URIENT
CARE OR DOCTOR'S OFFICE VISITS
SO THESE COSTS ARE WAY
UNDERESTIMATED AND THEN HIGH
SCHOOL AGED ATHLETES AND MALES
ARE 2 GROUPS THAT GENERALLY HAVE
A HIGHER COST OF SPORTS YOURED
AND IF WE WANT TO PROVIDE JUST
FOR A VERY SPISK SPRAIN, THE
SOCIETAL COST IS ESTIMATED TO BE
ABOUT $10,000.
SO CURRENT ESTIMATE SUGGESTS
THAT THE COST IS SUBSTANTIAL BUT
WE NEED MORE WORK IN THIS AREA
TO BETTER UNDERSTAND WHAT THE
FIEP ACIAL BURDEN IS.
AND LIKE I SAID BUYER I GOT
STARTED THERE'S A TON OF SPORTS
INJURIES IING TALK ABOUT AND I
STRUGGLED FOR A BIT OF TIME WITH
WHICH 1S TO PRESENT TO YOU
TODAY.
BUT I PUT THE SLIDE UP THERE TO
SHOW YOU THERE'S INJURIES
OCCURRING TO THE HEAD, NECK,
TRUNK, TO THE UPPER AND LOWER
BODY ISSUE THE VAST MAJORITY OF
SPORT INJURIES, HALF OF SPORT
INJURIES OCCUR TO THE LOWER
BODY, ROUGHLY 50% IF YOU LOOK AT
THAT GRAPHIC HERE, THAT'S WHAT
YOU WILL SEE.
AND THEN ABOUT 30% TO THE HEAD,
NECK AND TRINK AND THEN THE LAST
20% ARE UPPER EXTREMITY SO I
LISTED OUT SOME OF THOSE YOURS
MIGHT BE AND AGAIN THIS IS NOT
AN ALL-INCLUSIVE LIST.
AND THEN I BOLDED 3 YOURS THEY
WILL SPEND TIME TALKING TO YOU
ABOUT TODAY IN A VERY
ACCELERATED WAY.
BECAUSE THEY'RE INJURIES THAT
HAVE LOCK TERM CONSEQUENCES AND
THEY CAN DO DONE TO IMPROVE
CARE.
SO LET'S TALK ABOUT THE SAMPLING
OF SPORTS INJURIES THAT I CHOSE
TODAY.
THE FIRST 1 IS ANKLE SPRAINS SO
IF WE LOOK AT BASIC FACTS, ABOUT
2 OF THESE OCCUR EACH YEAR AND
THIS IS A BIG UNDERESTIMATE
BECAUSE THIS NUMBER IS JUST
BASED ON ER VISITING AND MOST
WILL BE NOT GET TO THE ER, THEY
WILL BE SEEN BY A PHYSICAL
TRAINER OR CAREGIVER.
SO THIS IS A MASSIVE INACCURATE
REPORTING.
FEMALES ALSO HAVE A HIGH
EN--STRATEGIES DENSE OF INJURY
RATE, SO THEY SUSTAIN ABOUT 14
FRAMES PER EXPOSURES VERSUS MEN
WHO GET 7 SPRAINS FOR THOUSAND
EXPOSURES, KIDS AT 12 ARE MOST
AT LIFIC FOLLOWED BY ADOLESCENT
ANDS THEN ADULT ANDS THEN
ATHLETES THAT ARE PARTICIPATING
IN COURT SPORTS ARE AT MORE RISK
THAN FOLKS PARTICIPATING IN
OTHER SURFACES.
PROBABLY WHAT'S MOST ALARMING
ABOUT THIS IS THAT THE ANKLE
SPRAINS HAVE THE HIGHEST
OCCURRENCE OF ALL MUSK LO
SKELETAL INJURIES.
THERE'S A 2 FOLD INCREASE IN
RISK IN THE YOUR FOLLOWING YOUR
AND OCCURRENCE AND GENERALLY
SPEAKING PROBABLY ALL OF YOU ON
THIS CALL, YOU THINK OF AN ANKLE
SPRAIN YOU THINK OF IT AS A
RELATIVELY INSIGNIFICANT INJURY,
BUT ISN'T.
IT HAS A LONG-TERM COST AND
DISABLES SHOASHTED WITH IT.
I WANT TO MENTION THERE'S A
BUNCH OF DIFFERENT TYPES OF
ANKLE SPRAINS, I SHOW 3 TYPES,
INVERSION ANKLE SPRAINS AND HIGH
ANKLE SPRAINS, THE MOST COMMON
TYPE THAT WE'RE DEALING WITH AND
THE 1S THAT CAUSE A LOT OF
LONG-TERM COMPLICATIONS WERE
THESE INVERSION ANKLE SPRAINS
OVER LATERAL ANKLE SPRAINS AND
THESE TURN WHEN THEY'RE FORCED
INWARD AND CAUSES THE LIGAPTS OR
THE LIGAMENTS ON THE OUTSIDE OF
THE ANKLE TO TEAR AND THESE
LATERAL ANKLE SPRAINS HAVE A
HIGH EN--STRATEGIES DENSE OF
LONG-TERM INSTABILITY, ABOUT
80-NIEBT% OF FOLKS WILL GO ON
AND OCCUR IN STABILITY WITH THIS
INJURY.
SO CHRONIC ANKLE INTAIBILITY AND
THE POGHT ALGORITHMS OF RESIDUAL
SYMPTOMS AFTER AN INITIAL
SPRAIN.
SO THIS IS THOUGHT TO OCCUR FROM
2 MAIN REASONS, THIS MECHANICAL
INSTABILITY THAT MAY PERSIST,
AND/OR DISFUNKAL INSTABILITY
THAT PATIENTS DESCRIBE EMPLOY SO
THE MECHANICAL INSTABILITY IS
THE RESULT OF INCREASED LAXITY
OR LOOSENESS IN THE JOINT AND
THEN ARGT ROW KINEMATIC
FUNCTIONAL AFTER THE SPRAIN AS
WELL AS THE PATIENT MAY PERCEIVE
COMPLETE STABILITY RESTORE BUT
THEY'RE EXPERIENCING EXPERIENCF
GIVING WAY AND THEY CALL THAT
FUNCTIONAL INSTABILITY PIECE.
IF YOU TAKE A LACK AT THE
LITERATURE AREYALATED TO THAT
AND WHAT ARE THE RISK FACTORS
THAT PERPETUATE WHETHER SOMEBODY
GOES ON TO THIS VERSUS SOMEBODY
THAT DID NOT, IF YOU LACK AT THE
ITEMS ON THIS GRAPHIC THAT ARE
HAVE BIGGER TEXT, THESE ARE THE
FACTORS THAT HAVE BEEN
REPETITIVELY OVER AND OVER
AGAIN, META-ANALYSIS SHOWN TO
REALLY PLAY A ROLE IN WHETHER
SOMEBODY GOES ON TO TWEP CHRONIC
ANKLE INSTABILITY.
SO THE PERO NEAL MUSCLES WHICH
ARE THE EVETERINARY COMMUNITIER
MUSCLES OF THE FOOD THAT WILL E
SPHOND THIS INVERSION MOTION WE
SEE WITH THE LATERAL ANKLE
SPRAIN, IF THE PERO NEAL MUSCLES
ARE WEEK OR DON'T REACT AS
QUICKLY TO AN INVERSION TYPE
MOTION.
THESE FOLKS WILL GO ON AND HAVE
INSTABILITY, ALSO THEY HAVE
FOLKS WHO HAVE TO JUMP FORWARD
OR PERFORMING VARIOUS REACH TYPE
ACTIVITIES, WHILE BALANCING ON
THE LEG, FECES THAT HAVE BALANCE
DEFINITES IN THESE WAYS ARE MORE
LIKELY TO GO ON AND SUFFER
CHRONIC INSTABILITY.
AND THE SMALLER 1S DOWN AT THE
BOTTOM, THERE'S BEEN IN STUDIES
THAT HAVE SHOWN THAT PROPRIMATES
O ACCEPTION OR STANDING ON LEGS
WITH EYES CLOSED CAN BE A FACTOR
FOR CHRONIC ANKLE INSTABILITY
BUT THERE'S NOT AS MUCH EVIDENCE
TO SUPPORT THOSE.
I USE THIS SLIDE BECAUSE BASIC
LYE ONCE YOU SUSTAIN AN ANKLE
SPRAIN THERE'S A HIGH LIKELIHOOD
OF THIS SMOA BALL EFFECT THAT
OCCURS EMPLOY SO THERE'S ACUTE
ANKLE SPRAIN, MOST OF WHICH WILL
GO ON TO LEAD TO THIS RECURRENT
INSTABILITY OR CHRONIC
INSTABILITY OF THE JOINT AND
THEN A GOOD NOB OF PEOPLE WHO
HAVE A SINGLE ANKLE SPRAIN OR
RECURRENT INSTABILITY WILL GO ON
AND DEVELOP POST-TRAUMATIC
OSTEOARTHRITIS.
SO THIS CONTRIBUTES TO TWEBT% OF
ALL OSTEOARTHRITIS CASES THAT
INVOLVE THE ANKLE AND 80% OF THE
OSTEOARTHRITIS CASES THAT
INVOLVE THE ANKLE.
PATIENTS WITH END STAGE, THEY
HAVE A FASTER LOSS OF FUNCTION
AND PROGRESSION TO
OSTEOARTHRITIS.
THE PHYSICAL BURDEN THAT'S
ASSOCIATE WIDE POST-TRAUMATIC OA
IN THIS POPULATION HAS BEEN
COMPARABLE TO THAT REPORTED BY
PATES WITH KIDNEY DISEASE,
CONGESTIVE HEART FAIL AND YOU
ARE CERVICAL PAIN AND RADICKUE
LOPATHY.
SO IT'S A BIG PROBLEM THAT NEEDS
SOME WORK.
AND SO 1 OF THE THINGS I WAS
ASKED TO DO WAS TALK ABOUT
RESEARCH DOMAINS THAT MIGHT BE
ASSOCIATE WIDE ANKLE SPRAINS OR
ANKLE INSTABILITY RESEARCH AND I
WOULD SAY SPORTS MEDICINE IN
GENERAL WE LACK CLINICAL TRIALS
TO SHOW WHICH TREATMENTS ARE
MORE CENTER FOR EXCELLENCE ON
AGINGIVE, AND SO THAT'S A BIG
MESSAGE THAT I'M HOPING TO
ACCEPTED TODAY IS THAT WE JUST
DON'T HAVE THE DATA TO SAY, HEY,
DOING REHABILATION AND WHAT TYPE
OF REHABILITATION AND WHAT
INTERVENTIONS SHOULD BE PART OF
THE REHABILITATION ARE EFFECTIVE
EMPLOY THAT DATA DOESN'T EXIST
AND WE DON'T HAVE A--WE DON'T
HAVE LARGE PROSPECTIVE STUDIES
THAT LOOK AT WHAT FACTORS
CONTRIBUTE TO LINGERING
INSTABILITY AFTER ANKLE SPRAINS
AND WHAT FACTORS LEAD TO
OSTEOARTHRITIS OR ANKLE SPRAINS
SO THERE'S A WHOLE LOT OF THINGS
THAT FOLKS COULD BE DOING TO
IMPROVE OR FILL RESEARCH GAPS IN
THIS AREA.
THE SECOND INJURY THAT I'M GOING
TO TALK ABOUT IS ANTERIOR
CRUCIATE LIGAMENT, THIS IS THE 1
WE SPEND ALL OF MIEM TIME BASIC
LYE STUDYING, ANTERIOR CRUCIATE
LIGAMENT STUDIES ARE THE MOST
COMMONLY INJURED KNEE █LIGAMENT,
IT'S THIS LEGAMENT, YOU SEE HERE
IN THE FRONT OF THE KNEE IF I
CAN GET MY MOUSE TO SHOW, AND IT
CONNEBS THE FEMUR TO THE TIBIA,
PRIMARYIA BE TO PROY VENT THE
TIBIA FROM SLIDING FORWARD ON
THE FEMUR AND IT PREVEBTS ROTARY
INSTABILITY AT THE KNEE.
300,000 OF THESE INJURIES OCCUR
ANNUALLY.
FEMALES SUFFER THESE INJURIES AT
A GREATER RATE THAN MALES BUT IF
WE WERE TO LOOK AT THE OVERALL
NUMBER OF ACL INJURIES THAT
OCCUR IN THE UNITED STATES,
THERE'S A GREATER NUMBER OF MALE
INJURIES BUT THE RATES ARE
HIGHER IN FEMALES.
THIS INJURY HAS GOTTEN A LOT OF
ATTENTION AS FAR AS HOW MUCH
MONEY IS SPENT ON IT, THERE'S
BEEN A LOT OF GOOD QUALITY
STUDIES RELATED TO THAT WHY UOF
THE ON THIS INITIAL INJURY ALL
THE WAY THROUGH POST-TRAUMATIC
OUTCOMES, 8 BILLION THERE IS
GETS SPENT ON THIS INJURY
ANNUALLY.
ONE THING I WANT TO POINT OUT IS
THAT IT'S A AN YOUR THAT OCCURS
OFTEN IN YOUNG ADOLESCENT ADULTS
WITH A PEAK AGE OF A TEAR
OCCURRING AT 14.
AND ABOUT 50% OF THE PEOPLE THAT
TEAR AN ACL, WHETHER THEY HAVE
SURGELY OR THEY DO NOT TO FIX
THAT INJURY ARE GOING TO GO ON
AND DEVELOP OSTEOARTHRITIS
WITHIN 10 YEARS OR SOME EVIDENT
OF IT WITHIN 10 YEARS AND I WANT
TO YOU PUT THOSE LAST 2 PIECES
TOGETHER, THEY TEAR AN ACL AT 14
AND BY 24 THEY CAN HAVE
ARTHRITIS IN THEIR KNEE WHICH
WOULD AFFECT THEIR PHYSICAL
FUNCTION FOR A LANGUAGE TIME TO
COME EMPLOY SO 1 THINK THIS I
FOCUSUS A LOT OF MY RESEARCH ON
IS MANY PATIENTS THAT ARE
GETTING RETURNED TO SPORT OR
RETURN TO ACTIVITY, WHATEVERRA
THEY'RE GOING TO DO AFTERWARDS
HAVE INADEQUATE RECOVERY.
THESE PATES ARE DOING AT LEAST 9
MONTHS OF REHABILITATION,
THEY'RE IN THE CLINIC ALL THE
TIME, THEY HAVE THIS BIG
SURGERY, AND THE FACT OF THE
MATTER IS, HOW WE'RE TREATING
THEM IS CENTER FOR EXCELLENCE ON
AGINGIVE AT RESTORING MECHANICAL
STABILITY OF THE JOINT BUT IT'S
NOT--IT'S NOT EFFECTIVE AT
IMPROVING LONG-TERM KNEE JOINT
HEALTH OR SUSTAINING LONG-TERM
KNEE JOINT HEALTH EMPLOY THEY
HAVE INADMIN RECORDS AND QUAIT
RECOVERY.
SO WHAT ARE SOME OF THE
CONSEQUENCES OR WHAT ARE WE SEE
ON ACL PATIENTS THAT ARE IN THE
CLINIC THAT ARE LINGERING ISSUES
ARE, 1 OF THE BIG 1S WE SEE IS
THAT 4 OUT OF 5 PATIENTS WHEN
THEY'RE CLEAR TO RETURN TO SPORT
AND FOR YEARS AFTER THEIR RETURN
TO SPORT OR ACTIVITY WILL HAVE
QUADRICEPS WEAKNESS, SO IT'S A
LARGE PERCENT OF THESE FOLKS,
THIS TOP SLIDE SHOW ATROPHY IN
THIS PERSON EARLY AFTER SURGERY
BUT I TEST A LOT OF PATIENTS
COME INTO MY LAB AND I SEE THEM,
THERE'S CLINICAL RECOMMENDATIONS
ABOUT WHAT THEY'RE SUPPOSED TO
BE ACHIEVING AND IT'S SUPPOSED
TO BE 90% STRENGTH OF THE CONTRA
LATERAL SIDE AND THERE'S EVIDENT
TO SUPPORT IF YOU CAN ACHIEVE
THAT, YOU'RE LESS LIKELY TO TEAR
YOUR GRAFT, OKAY, I WILL SAY,
40% OF THE PATIENTS THAT COME
THROUGH MY LAB ACTUALLY ACHIEVE
THAT AT THE TIME THEY RETURN TO
ACTIVITY YET THEY GO BACK TO THE
SPORT ANYWAYS WHICH IS PROBABLY
A REASON WE ARE A HIGH RATE OF
RECURRENCE OF THIS YOUR.
OTHER FACTORS THAT WE SEE THAT
ARE COMMON AFTER ACL YOUR ASK
RECONSTRUCTION OF THAT
LIGAMILLIO, IS THAT WE SEE
BIOMECHANICAL CHANGES AT THE
JOINT EMPLOY SO THE WAY PEOPLE
ARE WALKING OR COMPLOATING THEIR
ACTIVITY, THEY'RE MOVING THEIR
JOINT IN DIFFERENT WAYS AND
DIFFERENT LOADS ARE HAPPENING
ABOUT THE JOINT.
SO WE SEE THAT 1 OF THE
CHARACTERISTIC PAT OTHER THANS
IS THAT FOLKS TEND TO UNDERLOAD
THEIR ACL LIMB, SO THE LEG THAT
WAS AFFECTED WITH THE ACL TEAR,
THEY HAVE LESS VERTICAL GROUND
REACTION FORCES WHICH MEANS LESS
LOADS GOING UP FROM THE GROUND,
SMALLER CONTACT FORCES OCCURRING
AT THE NEED, SMALLER JOINT
MOMENTS OCCURRING AT THE KNEE,
SOPHISTICATEDY THEY TEND TO
AVOID THAT LIMB BUT THIS
AVOIDANCE OF THAT LIMB HAS BEEN
LINKED TO BIOMARKERS OF AFTIO
ARTHRITIS AS HAS THE QUADRICEPS
WEAKNESS BEEN LINKED TO
ARTHRITIS AND REINJURY.
THESE FOLK VS LESS FUNCTIONAL
PERFORMANCE AND YOU CAN DEFINE
THAT IN A VARIETY OF WAYS, THEY
DON'T HOP AS FAST OR AS LONG,
THEY CAN'T RUN AS FAST, THEY ARE
NOT PERFORMING AS WELL AS
BEFORE.
THERE IS ABOUT A 20% INDENSE OF
A RETEAR OF THE GRAFT IN THESE
PATES SO 1 IN 5 ATHLETES WILL
RETEAR THEIR GRAFT AFTER THEY'VE
GONE THRU THIS MASSIVE SURGERY
AND HAVE SPENT 9 MONTHS
REHABILITATING THEIR LIMB AND
THEY WILL GO ON AND RETEAR, AND
14% TEAR THE OTHER ACL ON THE
OTHER SIDE OF THE LEG.
THESE FOLKS HAVE LESS, THEY'RE
MEETING OUR U.S. REQUIREMENTS
FOR PHYSICAL ACTIVITY OR
RECOMMENDATIONS FOR A PHYSICAL
ACTIVITY, THEY'RE DOING IT 2.36
TIMES LESS THAN WHAT IS
RECOMMENDED EVEN WHEN THEY
SUCCESSFULLY REPORTED BY THE
PATIENT GO BACK TO SPORT.
AND ABOUT--AGAIN, LIKE I SAID
SAID PEOPLE 50% OF THE PEOPLE
ARE GOING TO TO DEVELOP
POST-TRAUMATIC OSTEOARTHRITIS.
SO I BORROWED THIS SLIDE FROM A
RESEARCHER OUT IN EUROPE AND HE
DEVELOPED THIS A WHILE BACK CAN
APPROXIMATE HE WAS LOOKING AT
ALL THE FACTORS THAT COULD LEAD
TO AFTIO ARTHRITIS AND THERE'S
NOT EVIDENT TO SUPPORT ALL OF
THESE, THESE ARE THINGS THAT
COULD AFFECT IT, THERE IS SOME
EVIDENCE THAT COULD SHOW THE
AGE, SEX AND TIME OF INJURY DO
AFFECT OA RISK BUT I CIRCLED 1S
THAT ARE MODIFIABLE IS DEEMED TO
HAVE STRONG REHABILITATION AND
INTERVENTION TO SUPPORT THEM.
SO FOLKS WITH HIGHER BMI ARE
MORE LIKELY--THERE'S EVIDENCE
THAT SUPPORTS THAT, THEY HAVE
EARLIER CARTILAGE DEGENERATION.
THIS DECREASED JOINT LOADING
THAT I TALKED ABOUT OR THIS
UNDERLOADING HAS BEEN LINKED TO
BIOMARKERS OF OSTEOARTHRITIS,
IT'S PROBABLY THE 1 THAT IS MOST
SIGNIFICANT OR HAS THE MOST
RESEARCH ASSOCIATE WIDE IT RIGHT
NOW IS THAT AS EARLY AS 4 MONTHS
AFTER SURGERY FYOU HAVE A WEAKER
QUADRICEP OR AN EQUAL
COUNTERPART TO YOU, YOU ARE MORE
LIKELY TO DEVELOP RADIO GRAPHIC
EVIDENCE OF AFTIO ARTHRITIS
WITHIN A FEW YEARS.
SO FOCUSING ON SOME OF THESE
RICK FACTORS ARE GOING TO BE
CRITICAL TO RHETORRING LONG-TERM
JOINT HELP FOR THESE FOLKINGS
AFTER ACL RECONSTRUCTION.
SO AGAIN, THESE RESEARCH DOMAINS
ARE THINGS WE NEED TO WORK ON,
THEREYA A TON OF THEM.
ACLs ARE PROBABLY THE MOST
RESEARCHED SPORTS INJURY THAT WE
HAVE, BUT THAT BEING SAID,
THERE'S STILL SO MANY GAPS THAT
NEED TO BE FILLED, A LOT OF
THESE RESEARCHER OR CASE CONTROL
STUDIES OR COHORT STUDIES,
THEY'RE NOT PROTECTIVE STUDIES,
THEY'RE NOT RANDOMIZED CLINICAL
TRIALS WHICH WE DESPERATELY NEED
IN SPORT INJURY RESEARCH AND ACL
RESEARCH.
FOCUSING ON JUST ON
REHABILITATION WE HAVE STANDARD
OF CARE ACL REHABILATION, IT DID
A GREAT JOB OF RESTORING
MECHANICAL STABILITY ALONG WITH
RESTORING RANGE OF MOTION AND
GETTING PEOPLE TO RETURN TO
ACTIVITY.
POST PEOPLE ARE RETURNING TO
SOME LEVEL OF ACTIVITY BUT
WHETHER THEY'RE DOING IT SAFELY
OR NOT IS DEBATABLE SO AGAIN WE
HAVE A LOT OF LINGERING
LINGERING DEFICITS
WHEN THESE PEOPLE GO BACK
SPHORTS AND WE NEED TO TEST
SYSTEMATICALLY ENTERVENTIONS
THAT HAVE THE POTENTIAL AND HAVE
EVIDENCE BEHIND THEM TO RESTORE
MUSCLE FUNCTION AND
BIOMECHANICAL ABNORMALITY ANDS
THAT STUFF IS GREAT AND THERE'S
A VARIETY OF OTHER THINGS AND 1
OF THE BIGGEST THINGS THAT'S AT
ISSUE FOR ME IS BRIDGING THE GAP
BETWEEN RESEARCH AND CLINICAL
PRACTICE, I WISH I HAD A MAGIC
WAND I COULD WAVE AND MAKE THE
FOLKS IN THE CLINIC USE THE
THINGS WE KNOW IN RESEARCH,
STRENGTH IS 1 OF THOSE THINGS, I
CAN'T EVEN GET FOLKS TO MEASURE
STRENGTH IN THE CLINIC BEFORE
THEY RETURN SOMETHING TO THE
SPORT, IT'S HARDER TO DO BECAUSE
THEY HAVE TO PUT THEM ON THE BIG
DEVICE, SO HAVING DEVICES
AVAILABLE TO MAKE THINGS EASIER
FOR CLINICIANS TO USE AND BE
ABLE TO IMPLEMENT RESEARCH IN A
CLINICAL PRACTICE WOULD BE VERY
BENEFICIAL.
THE LAST INJURY I WANT TO SPEBD
A COUPLE MINUTES ON IS SHOULDER
IPT GREATER STABILITY, I WANT TO
GIVE US SOMETHING FROM THE UPPER
BODY.
SHOULDER INSTABILITY IS AN
INJURY WITH BASICALLY REFERRING
TO THE LOSS OF THE ABILITY TO
MAINTAIN NORMAL JOINT ALIGNMENT.
AND SO IF YOU TAKE A LOOK AT
THIS GRAPHIC HERE, WE HAVE A
LOOK AT THE DPLEN O HIEWMERAL
JOINT, THE SCALPULA, AND WHEN WE
SEE DISLOCATIONS OR WE SEE
INSTABILITY WHERE THE HIEWMEROUS
MOVES AROUND THE SURF FASOF THE
THE GLENOID FOSA, IT CAN BE AN
INSTABILITY, IT COULD HAVE
TRAUMATIC CAUSES, IT WE CAN HAVE
THIS INSTABILITY THAT LEADS TO
PAIN, NUMBNESS, TINGLING THAT
HAPPEN AT THE YOIP AFTER THIS
AND CAN HAVE TRAUMATIC AND
A-AWMATTIC CAUSES, THE MOST
COMMON CAUSE OF SHOULDER
INSTABILITY IS TRAUMATIC JOINT
TRAUMA FROM THE SHOULDER.
SO FOLKS THAT HAVE DIFFERENT
CONGENITAL BONY SHAPE,
CONGENITAL SHAPE OF THEIR BONE
SO THEIR FLENNOID PROCESS IS
FLATTER THAN OTHERS, FOR
EXAMPLE, OR LAXITY OF THE
LIGAMENTS FROM REPETITIVE
THROWING OR OVERHEAD MOTION
WHICH WOULD BE ARK TRAUMATIC CAN
ALSO LEAD TO INSTABILITY.
GIVEN THE TRAUMATIC OR
DISLOCATION IS THE MOST COMMON
CAUSE OF INSTABILITY, JUST 1
DISLOCATION DOES NOT MEAN
SOMEONE HAS SHOULDER
INSTABILITY, INTAIBILITY NEEDS
TO BE RECURRENT SYMPTOMATIC
DISLOCATIONS OR SUBLEXATION OF
THAT JOINT.
BUT 50% OF THE TEEM THAT SOMEONE
SUSTAINS AN ACUTE DISLOCATION,
IT'S GOING TO BECOME RECURRENT.
SO HALF THESE PEOPLE WILL GO TO
TO DEVELOP THIS RECURRENT
INSTABILITY AFTER A TRAUMATIC
EVENT AND USUALLY THE TIME FOR
THIS TO OCCUR IS LESS THAN 1
YEAR.
SO IT'S HAPPENING PRETTY
QUICKLY.
SO WHAT'S THINGS ABOUT SHOULDER
INSTABILITY WE SHOULD KNOW, IT'S
MORE COMMON IN ATHLETES PEOPLE
USING THEIR SHOULDER IN CONTACT
SPORTS, THE MOST COMMON TYPE OF
INSTABILITY THAT WE SEE IS
ANTERIOR WHERE THIS HUMORAL HEAD
MOVES FORWARD, ON THE GLENOID
FOSSA, CONTACT FORS SO FOOTBALL,
LACROSSE, RUGBY WHERE THERE'S
THINGS WITH CONTACT FOR ATHLETES
WELL AS WELL AS OVERHEAD SPORTS
WHERE SEE SEE THIS LAXITY
DEVELOP OVERTIME AS FOLKS USING
THEIR ARM.
THERE'S AN INCREASE RISK OF
POST-TRAUMATIC OFTIO ARGT RIGHTS
IN THIS POPULATION, 62% OF PATES
DEPENDING ON WHICH STUDY YOU
LOOK AT, MAY DEVELOP
POST-TRAUMATIC OSTEOARTHRITIS
AND THERE WAS 1 STUDY THAT
FOLLOWED PATIENTS AFTER AN ACUTE
DISLOCATION FOR 25 YEARS.
AND THEY FOUND THAT THE
STANDARDIZED MORTALITY RATE IN
PATIENTS WITH SHOULDER
DISLOCATION WAS TWICE AS HIGH AS
WOULD BE EXPECTED IN THE GENERAL
POPULATION.
SO THERE MAY BE AN INCREED
MORTALITY RATE WITH THIS
INCREASE AS WELL.
SO WHAT ARE SOME RISK FACTORS
FOR SHOULDER INSTABILITY, MOST
OF THESE, MOST OF THE 1S WE KNOW
OF, AT THIS POINT IN TIME, ARE
NONMODIFIABLE, SO MORPHOLOGY,
LIKE THE GLENOID FOSSA, LONGER
AND TALLER RATHER THAN SHORTER
AND WIDER.
THE HIEWMEROUS DOESN'T SIT AS
CLOA CLOSE TO THE COTTERACOID
PROCESS, THERE'S DATA THAT SHOWS
THAT CHILDREN WITH CLOSED
[INDISCERNIBLE] PLATES ARE MORE
LIKELY TO HAVE RECURRENT
INTAIBILITY THAN FOLKS WITH OPEN
PLATES SO SOME OF THESE THINGS
THERE'S NOTHING, WE CAN'T DO
ANYTHING ABOUT THOSE THINGS,
THERE'S NOTHING THERE, SEX,
MALES ARE MORE LIKELY, AGE,
PEOPLE UNDER 20 ARE MORE LIKELY
TO EXPERIENCE RECURRENT
INSTABILITY.
TYPE OFACKIVITY THAT YOU'RE
PARTICIPATING IN, CONTACT OR
OVERHEAD ACTIVITY.
YOU'RE ABOUT 3 TIMES MORE LIKELY
THAN OTHER SPORTS.
SO CAN YOU CHANGE YOUR ACTIVITY,
BUT WE'RE TRYING TO NOT MAKE
PEOPLE CHANGE ACTIVITY.
THE 1 FACTOR THAT'S BEEN STUDIED
THAT MAY PLAY A ROLE, BUT
THERE'S NOT A LOT OF RESEARCH,
IS ROTATOR CUFF WEAKNESS, NOT A
FACTOR FOR FIRST TIME
DISLOCATIONS BUT SOME EVIDENCE
THAT SHOWS THAT WEAKNESS OF THE
ROTATOR CUFF MAY BE ASSOCIATE
WIDE RECURRENT ANTERIOR
INSTABILITY.
SO THAT WOULD BE SOMETHING THAT
WE COULD DEFINITELY TARGET WITH
REHABILITATION INTERVENTIONS TO
PREVENT RECURRENT INSTABILITY.
AGAIN WE'VE DONE, THERE'S A
WHOLE--THERE'S A SLEW OF
ACTUALLY SHOULDER STABILIZATION
PROCEDURES, SO LATTER JET,
[INDISCERNIBLE] ARGTROSCOPY,
OPEN [INDISCERNIBLE] AND OTHERS,
SO KNOWING WHICH 1 OF THOSE ARE
BEST AND DOES REHAB NEED TO BE
INDIVIDUALIZED TO THE TYPE OF
SURGERY OR TO THE PATIENT AND
THEIR SYMPTOMS OF RECURRENT
INSTABILITY, THAT NEEDS TO BE
LOOKED AT, WHAT ARE THE
MODIFIABLE FACTORS WE COULD
TARGET WITH REHABILITATION TO
HOPEFULLY PREVENT REINSTABILITY,
PREVENT POST-TRAUMATIC
OSTEOARTHRITIS.
WHAT ABOUT RETURN TO ACTIVITY,
THAT WILL LEAD TO BETTER JOINT
OUTCOMES, WE DON'T KNOW THAT
EITHER AND ALL THIS NEEDS TO BE
STUDIED.
THERE'S A LOT OF GAPS
GAPS THAT NEED
TO BE FILLED.
I WANT END WITH 2 SLIDES I WAS
ASKED MAYBE YOU ALL WOULD BE
INTERESTED IN SURGICAL VERSUS
NONSURGAL TREATMENT OPGS.
IT'S TOO MUCH FOR ME TO GO
THROUGH THE SURGICAL IF VERSUS
REHAB FOR ALL THE INJURIES BUT I
THOUGHT IT WOULD BE INTERESTING
TO SEE THAT SURMRY DOES NOT HELP
PREVENT AGAINST AFTIOARTRITIS.
IF YOU TAKE A ELECTRIC AT
META-ANALYSIS OF CLINICAL
TRIALS, THERE'S NOT A LOT OF
EVIDENT THAT SUPPORTS THAT ACL
SURGERY REDUCES THE RISK OF OA.
IN FACT IF YOU LOOK AT A LOT OF
THE STUDIES THAT RCTs ARE
NOT--THE INCIDENCE RATE IS ABOUT
THE SAME.
SHOULDER INSTABILITY, THE STUDY,
1 STUDY THAT LOOKINGAD THIS THAT
SHOWED THAT 33% OF PATIENTS THAT
UNDERWENT SURGERY, DISPLAYED
RADIO GRAPHIC SIGNS OF OA WHILE
24% OF NONOPERATIVE FOLKS
DISPLAYED SIGNS OF OA,
SUGGESTING THAT SURGERY IS NOT
PROTECTIVE IN THE LEAST.
AND AS FAR AS CHRONIC ANKLE
INSTABILITY, THERE'S NO STUDY
FOR ME TO POINT TO, USUALLY
CHRONIC ANKLE INTAIBILITY IS
TREATED CONSERVATIVELY FIRST.
AND IT'S USUALLY TREATEDON
SERVAATIVELY BEFORE 6 MONTHS
BEFORE THEY MAKE A DECISION TO
GO IN AND TREAT THAT FOR SURGERY
BUT THIS' NO STUDY THAT COMPARES
SURMRY VERSUS REHAB.
AND THEN LAST BUT NOT LEAST IS
THERE'S VERY LITTLE EVIDENCE
BASED REHABILITATION SCIENCE IN
SPORTS MEDICINE.
WE TEND TO THROW THE KITCHEN
SINK AT THING ANDS HOPE IT WORK
ANDS IT'S NOT.
SO WE NEED TO REALLY USE RCTs
FOR EVIDENCE BASED
REHABILITATION PROGRAMS,
ELECTRIC AT INDIVIDUALIZED
REHABILITATION STRATEGIES, THE
DOSAGES OF ISHT VENTIONS BEING
USED ARE BASICALLY BEST GUESSES
AND NOT REALLY WELL STUDIED.
ASK WE NEED TO HAVE
EVIDENT-BASED CRITERIA TO RETURN
PEOPLE TO SPORT ACTIVITY AMONGST
OTHER THINGS.
SO THANK YOU FOR YOUR TAME AND
ATTENTION I'M HAPPY TO FIELD ANY
QUESTIONS YOU MIGHT HAVE.
>> ARE WE OPEN TO DISCUSSIONS
AND QUESTIONS, YES IN LINDA?
YOU'RE MUTED.
>> THANK YOU.
THAT WAS A GREAT TALK IN 20
MINUTES.
SO I FOLLOW YOU SO I FEEL YOUR
PAIN.
I'M REALLY INTERESTED, I READ A
LOT ABOUT THE ACL, IN THE ACL
LITERATURE, CAN YOU TALK ABOUT
1, WHETHER THE AMOUNT OF REHAB
HAS ANYTHING TO DO WITH REINJURY
IN AND THEN THE OTHER IS LIKE
PSYCHOLOGICAL FACTORS, SO THOSE
ARE BIG IN BACK PAIN BUT I'M
WONDERING WHERE THAT IS IN THAT
LITERATURE WITH REGARD TO ACL
YOURS?
>> SO THE AMOUNT OF REHAB,
THERE'S NO DATA FOR ME TO GO OFF
OF.
LITERALLY FOR A VERY LONG PERIOD
OF TIME, PEOPLE JUST WERE
RETURPING PEOPLE TO SPORTS BASED
ON TIME, BUT IT WASN'T TIME
BASED ON WHETHER THE GRAFT WAS
HEALED OR ANYTHING, IT WAS LIKE
6 MONTHS WE FEEL LIKE THAT'S A
GOOD SPOT, THEY CAN RUN THEN,
THEY CAN DO THINGS AND THEN THEY
PROGRESSED IT TO 9 MONTHS, AND
NOW AT 9 MONTHS WE FEEL PEOPLE
ARE READY TO BACK TO SPORT ORE
ACTIVITY BUT IF YOU LOOK AT
THESE PATIENT ANDS THEY COME IN
THE LAB AND TEST THE CRITERIA
THAT WERE SUGGEST SHOULD BE USED
TO RETURN SOMEBODY TO ACTIVITY,
THEY ARE NOT MEETING THEM.
SO WE NEED LONGER REHABILATION
IN MY OPINION OR MORE OF IT IN
THE 6 OR 9 MONTH PERIOD, BUT
IT'S VERY HARD WHEN YOU'RE
DEALING WITH A YOUNG ATHLETES
THAT ARE TRYING TO COMPETE FOR
TO GET INTO COLLEGES AND GET
SCHOLARSHIPS, YOU KNOW PARENTS
THAT REALLY WANT THESE KIDS TO
GO BACK IT SPORTS SO THEREYA A
PUSH TO GET PEOPLE BACK EARLIER
AND THERE'S EVIDENT TO SUPPORT
THAT THE GRAFTS NOT EACH HEALED
UNTIL ABOUT WOYEARS.
SO THE GRAFT TISSUE THAT THEY'RE
USING FOR THE SURGEERAL
RECONSTRUCTION, IT DOESN'T EVEN
MATURE UNTIL ABOUT 2 YEARS TO
THE EQUIVALENT OF THAT TO A
NATIVE ACL.
SO I WOULD SAY I DON'T HAVE A
GOOD ANSWER TBR THE AMOUNT OF
REHAB BUT I WILL SAY IS WHAT
WE'RE DOING IS INSUFFICIENT
BASED ON ALL EVIDENCE THAT WE
HAVE AND THEN AS FAR AS LIKE
DINNIESIA PHOBIA IS WHAT YOU'RE
ASKING ME ABOUT OR PSYCHOLOGICAL
FACTORS RELATED TO THAT?
>> YES NAND WHETHER TAKEN--THEY
RELATES TO REYOUR IN.
>> YEAH, I DON'T KNOW
THAT--THERE'S NOT GOOD EVIDENT
THAT IT RELATES TO GOOD INJURY
BUT THERE'S GOOD EVIDENT THAT AT
THE TIME PATIENTS RETURN BACK TO
SPORT OR ACTIVITY THERE'S A GOOD
AMOUNT OF KINNIESIA PHOBIA OR
CAN YOU SEE HOW THEY LOAD THE
JOINT OR HOP OR DO SOME SPORTS
ACTIVITY, THEY ARE NERVOUS TO DO
SO AND THERE'S EVIDENCE TO
SUPPORT LIKE THE TAMPA SCALE AND
OTHER VALIDATED METRICS THAT
THAT EXISTS AT THE TIME THEY
RETURN TO ACTIVITY AND BEYOND.
NTHANK YOU.
>> YOU'RE WELCOME.
>> I HAD SOME OF THE SAME
QUESTIONS.
YOU KNOW I WAS--I'M GLAD YOU
ACKNOWLEDGED THE INCREDIBLE
PRESSURE THESE KIDS ARE UNDER TO
RETURN TO SPORTS AND THAT
CREATES PORT OF A PROBLEM WITH
THE FAMILIES AND SO ON.
AND I THINK WHAT LINDA WAS--I
WANT TO MAKE SURE I UNDERSTOOD,
I WAS CURIOUS ABOUT HOW MUCH
WHEN PEOPLE ARE RECOVERING, NOT
JUST ATHLETES BUT OLD FOLKS LIKE
ME, THAT PEOPLE HOW MUCH OF IT
IS IN THEIR HEAD THAT BECAUSE
THEY'RE OVERPROTECTIVE, ABNORMAL
BEHAVIORS ARE CAUSING MORE
PROBLEM, I THINK THAT'S WHAT
LINDA WAS ASKING AND CAN YOU
HAVE PEOPLE GET PAST THAT?
>> YEAH, I THINK THAT'S PART OF
THIS UNDERLOADING I WAS TALKING
TO YOU ABOUT WITH THE
BIOMECHANICAL CONSEQUENCES.
PEOPLE TRY TO AVOID BEARING
WEIGHT ON THAT KNEE OR LOADING
THAT KNEE AND BY DOING THAT,
EVIDENT SUGGESTS THAT THEY'RE
CAUSING MORE LONG-TERM JOINT
HEALTH PROBLEMS FOR THEMSELVES.
IT'S AN INCREASED FOR RISK FOR
OSTEOARTHRITIS SO I DO THINK
THAT IF WE COULD IMPROVE SOME OF
OUR ABILITY TO--OR THE PASHT'S
ABILITY TO FEEL MORE CONFIDENT
IN THEIR KNEE AND MORE
FUNCTIONAL REHABILITATION YOU
WILL MAKE THEM FEEL THAT THEIR
KNEE IS MORE STABLE AND THAT
THEY CAN PERFORM TO THE SAME
LEVEL THEY COULD BEFORE THEN I
THINK THAT WOULD HELP BUT I
THINK THAT HALF THE PROBLEM IS
THAT WHEN THEY ARE GOING BACK TO
ACTIVITY, THEY CAN'T HAVE
CONFIDENCE BECAUSE THEIR KNEE IS
NOT THE SAME AS IT WAS BEFORE
EMPLOY THEY HAVE ALL THIS
WEAKNESS, AND IT'S NOT--BECAUSE
THEY'RE WEAK, THEY DON'T HAVE
GOOD DYNAMIC STABILIZERS
SURROWPPEDDING THE KNEE SO THEY
ARE LESS STABLE AND I THEY FEEL
IT SO IF WE COULD IMPROVE OUR
REHABILITATION TO MAKE THEM MORE
STABLE WE MAY BE ABLE TO BUILD
MORE CONFIDENCE BUT THAT'S NOT
TO SAY THAT PSYCHOLOGICAL
INTERVENTIONS WOULD BE OF VALUE
BECAUSE I DO FEEL THEY WOULD BE
OF VALUE EMPLOY I DON'T KNOW IF
THAT ANSWERS YOUR QUESTION, YOU
ABOUT I DON'T KNOW THERE'S A
WHOLE LOT OF DAT ON GO OFF, TOO.
>> THAT'S FINE, I WILL JUST SIGN
UP FOR YOUR CLINIC.
THANKS.
[LAUGHTER]
>> WE HAVE 4 QUESTIONS AND THEN
WE WILL FINISH UP WITH THOSE 4,
LINDA JOSEPH?
>> HI, TBRAIT TALK, MY QUESTION
IS SORT OF FOLLOWING UP ON
RALPH'S QUESTION AND IT HAS TO
DO WITH THAT, THE SAID THE
CHANGE TO BIOMECHANIC ANDS THEIR
LOADING.
SO MY QUESTION IS DO YOU KNOW OF
ANY RESEARCH THAT FOLLOWS THESE
GUYS AS THEY AGE TO SEE HOW IT
NOT ONLY EFFECTS THE INJURED
KNEE BUT UNYOURED KNEE IN
EMERGING ITS OF OA, ANY SORT OF
JOINT ISSUES?
>> I AM AWARE OF NO DATA THAT
HAS THAT TO FOLLOW THEM ALL THE
WAY OUT AND WHETHER THE
UNDERLOADING WOULD INFLUENCE THE
DEVELOPMENT OF BILATERAL OA FROM
AN IDIO PATHIC OA STANDPOINT WE
KNOW THERE'S A GOOD INCIDENCE OF
BILATERAL OA BUT I DON'T KNOW
WHAT THE INCIDENCE RATE IS OF
BILATERAL OA AND RELATED YOUR
AND WHETHER IT'S RELATED TO THE
BIOMECHANICAL CHANGES AFTER THE
INJURY.
I DO KNOW THAT THE WEAKNESS, THE
BIOMECHANICAL ADAPTATIONS, THERE
ARE STUDIES THAT HAVE SHOWN LIKE
2, 3, 4 YEARS AFTERWARDS THAT
THESE THINGS STILL LINGER.
>> DAWN?
>> VERY INTERESTING
PRESENTATION, QUICK FOLLOW UP ON
THE PSYCHOLOGICAL ASSPECS AS A
PSYCHOLOGIST I'M SITTING HERE
WONDERING AND MOM OF AN ATHLETE
WHO WAS INJURED, I'M WONDER
FIGURE ANYONE'S DOING RESEARCH
ON PSYCHOLOGICAL OUTCOMES AFTER
SPORTS YOURS, LOOKING AT RATES,
NOT JUST FACTORS THAT INFLUENCE
HOW THEY MOVE, BUT ADAPTATION,
AJUST ACCIDENT, DEPRESSION, ET
CETERA.
NYES, WELL ARE PEOPLE DOING THAT
TYPE OF RESEARCH BUT I WOULD SAY
THAT IT'S A SMALLER PROPORTION
OF THE RESEARCH THAT'S BEING
DONE AND IT'S AN UNDERSTUDIED
AREA THAT SHOULD CONTINUE TO GET
FOCUSED AND I THINK IN LIKE BACK
PAIN THAT THAT GETS STUDIED
QUITE A BIT.
ACL IT'S PICKED UP A BIT AND
CONCUSSION, THEY'VE BEEN
STUDYING THAT A LOT BUT I'M
NOT--NOT ACROSS ALL SPORTS YOURS
IF THAT HAPPENED.
BUT I WOULD SAY THE BIGGER 1S
ACL, CONCUSSION, BACK PAIN BUT I
HAVEN'T SEEN IT IN SHOULDER
BUTIME NOT REALLY INVEST INDEED
THAT LITERATURE BUT I'M NOT
AWARE OF MUCH OF IT THERE..
>> SHERRY?
>> THANKS AGAIN FOR YOUR AWESOME
TALK.
I WANTED TO ASK MAYBE LEAK A
LITTLE ZOOM OUT, 30,000-FOOT
VIEW, YOUR INPUT ON THE FUTURE
OF FUNDING IN THIS SPACE?
CLINICALLY, THIS IS WHERE MY
PRACTICE IS BASED ALSO MORE SO
ON THE MUSK LO SKELETAL SIDE AND
I KNOW THERE'S CONSISTENT
CHALLENGES WITH REGARD TO THE
LANDSCAPE OF FEDERAL FUNDING
OPPORTUNITIES FOR THIS TYPE OF
WORK, THERE'S SUPPLEMENTATION,
OF COURSE BY SOME OF THE SPORTS
MEDICINE FOCUSED MEDICAL
SOCIETIES THAT'S HELPFUL, BUT
CERTAINLY DIDN'T GET US TO THE
SAME LEVEL AS IT WOULD IF THERE
WERE LARGER GRANT PROGRAMS
THROUGH, YOU KNOW NIH FOR
EXAMPLE, SO WOULD LOVE YOUR
THOUGHTS ON KIND OF THE FUTURE
OF THAT SPACE, WHAT WOULD BE
HELPFUL, HOW WE ADVANCE THIS TO
THE NEXT LEVEL.
NWE NEED MORE FUNDING.
[LAUGHTER]
WE'RE ALREADY SAYING, YOU'RE
ALREADY SAYING THE THINGS THAT I
KNOW.
THERE ARE OPPORTUNITIES FOR
FUNDING IN THIS SPACE, I THINK
WE--AS A SPORTS MEDICINE
PROFESSION AS A WHOLE THAT
ENCOMPASSES A LOT OF DIFFERENT
PROFESSIONS WE NEED TO MAKE A
BETTER CASE FOR WHY FUNDING
NEEDS TO BE THERE.
PEOPLE NEED TO SEE THE COST OF
THESE INJURIES, LONG-TERM
CONSEQUENCES OF THESE INJURIES
AND THEN WHEN WE PROPOSE
REHABILITATION STRATEGIC PLAN
KNOWLEDGEYS, WE NEED TO PROPOSE
THINGS THAT ARE MECHANISTIC,
THERE'S SOME SORT OF MECHANISM
BEHIND THEM AND WE'RE JUST NO
THROT THROWING THE KITCHEN SINK
AT IT, HEY THIS, IS WORK OVER
HERE IN STROKE SO LET'S SEE IF
WE CAN MOVE IT OVER HERE AND USE
IT OR IT'S WORKED ON AN ANKLE
INJURY SO LET'S TRY IT IN A
SHOULDER YOUR.
THERE'S JUST NOT A LOT OF FOLKS
THAT ARE PROVIDING NECK
MECHANISTIC BASED INTERVENTIONS
AND THERE NEED TO BE A LAND CAPE
FOR THAT SO WE NEED TO
UNDERSTAND WHAT'S CAUSING THESE
AFTER YOUR AND THEN DEVELOP
REHABILITATION AND APPROACHES
THAT TARGET THOSE RISK FACTORS
THAT ARE KNOWN TO BE ASSOCIATED
OTHERWISE WE DON'T MAKE
PROGRESS.
>> THANK YOU.
NAND WRAPPING UP THE QUESTIONS
FRANCISCO IN.
>> THANK YOU.
JUST QUICKLY, I ALSO HAVE WORK
IN THIS FIELD, SOMETHING YOU
INTIMATED BUT I WANT TO SEE IF
YOU HAVE SORT OF AN OPINION ON
THIS ABOUT HOW WE'RE EVOLVING
FROM SEEING ACL OR ANKLE
INSTABILITY YOURS OR SHOULDER
INSTABILITY INJURIES HOW TO MOVE
AWAY FROM A STRUCTURAL
SIRNLGICAL TISSUE PROBLEM TO 1
MORE OF A SENSORY MOTOR CONTROL
AND ADAPTATION BECAUSE THERE'S
EVIDENCE OF COTTERRIC O
EXCITABILITY, DECREASES, ET
CETERA, JUST YOUR THOUGHTS ON
THAT?
>> YEAH, I THINK IT'S A
DIRECTION WE NEED TO MOVE IT.
WE'RE DOING SOME WORK IN THAT
SPACE RIGHT NOW, WHERE WE'RE
LOOKING AT DECREASED COTTERRIC O
EXCITABILITY IN THESE ACL
PATIENTS AND WE'RE LOOKING AT
OPERATE CONDITIONING USING
ELECTRICAL STIMULATION AND WE
WARDS BASED METHODS TO SEE IF WE
CAN IMPROVE THE EXCITABILITY
BECAUSE 1 OF THE ISSUES WITH
LET'S SAY THE WEAKNESS WITH ACL
RECONSTRUCTION IS NOT ALL ALL
MUSCLE SO WHEN SOMEONE TEARS
THEIR ACL, IT DOESN'T DAMAGE THE
QUADRICEPS MUSCLES BUT IT DOES
SHUT DOWN THERE IS RINKING THAT
UPON HAS AND ACCEPTEDS MESSAGES
FROM THE BRAIN.
AND SO IF THE BRAIN TELLING THE
MUSCLE NOT TO CONTRACT, WE CAN
TRY TO CONTRACT THE MUSCLE ALL
WE WANT BUT THAT NEURAL
INHIBITION IS NEVER GETTING
OVERCOME SO WE NEED TO TARGET
THESE OTHER YIRS SENSORY MOTOR
NEUROLOGICAL THAT ARE
CONTRIBUTING TO DEFICITS WITH
INJURY OR WE'RE NOT TARGETING
MECH INFORMS AND WE'RE NOT GOING
TO GET THIS FULL COMPLETE
REHABILITATION THAT NEEZ PATES
NEED AND DESERVE.
>> THANK YOU.
>> YOU'RE WELCOME.
>> WHOOPS DOUBLE CLICKING DIDN'T
WORK FOR THE MIC.
THANK YOU AGAIN.
LET'S GO ON AND HALF A
PRESENTATION BY DR. LINDA
VILLAIN DILLEN ON BACK INJURY.
>> ALL RIGHT.
WE WILL SEE IF I DO THIS
CORRECTLY.
>> LOOKS GOOD.
>> GREAT.
CAN YOU SEE MY NOTE WHICH IS IS
HELPFUL.
OKAY, SO THANKS FOR THE
INVITATION TO SPEAK TODAY TO THE
BOARD AND I ALWAYS LIKE BEING
THE LAST SPEAKER ON THE LAST
DAY.
IT'S A GREAT PLACE TO BE.
I DO APPRECIATE THE OPPORTUNITY
TO PAWK ABOUT THIS TOPIC, I
REALLY DEVELOPED AN INTEREST IN
BACK PAIN AS A CLINICIAN, I
WORKED WITH NEUROSCIENCE OR
NEUROMEDICINE AND NEUROSURGERY
AND I SAW A LOT OF PATIENTS WHO
GOT SURGERY TO RELIEVE THEIR
BACK PAIN AND THE AMOUNT OF
SURGERY THAT'S OCCURRING PER
BACK PAIN HAS CHANGED OVER THE
YEARS BECAUSE OF THE EVIDENCE
THAT'S BEEN GENERATED WHICH I
THINK IS REALLY ENCOURAGING.
SO, FIRST, I'M GOING TO TALK TO
YOU AND GIVE YOUA I BIG OVERVIEW
OF LOW BACK PAIN SO HAVE YOU AN
PREERK OF WHAT IT IS AND HOW
THESE CONDITIONS ARE QUITE
DIFFERENT FROM WHAT YOU HEARD
ABOUT THIS MORNING SO FAR.
I WILL TALK ABOUT THE POTENTIAL
CAUSES AND THE BURDEN AND THEN I
WILL GIVE YOU, DISCUSS WITH YOU
THE IMPORTANCE OF UNDERSTANDING
THE COURSE OF BACK PAIN TO STUDY
THESE CONDITIONS.
AND THEN I WILL PRESENT THE MOST
CURRENT RESEARCH INTO THE
POTENTIAL CONTRIBUTORS TO BACK
PAIN AND DISABILITY, THAT'S
ASSOCIATE WIDE IT AT I EMPHASIZE
DISABILITY HERE BECAUSE IT'S
BEEN DOCUM THAD THE INABILITY TO
PERFORM FUNCTIONAL ACTIVITY
SYSTEM THE PRIMARY REASON PEOPLE
WITH BACK PAIN ACTUALLY SEEK
INITIAL AS WELL AS SUBSIDIARY
QUEBT CARE RATHER THAN JUST THE
PEAP.
I WILL TALK ABOUT THE
BIOPSYCHOSOCIAL MODEL AS IT
APLAYS TO BACK PAIN AND THEN,
REVIEW THE MOST CONSISTENT
FINDINGS IN THIS AREA AND 1 OF
THE BIG TAKE HOMES THAT I'M
GOING TO TELL YOU NOW IS THAT
BACK PAIN IS A COMPLEX CONDITION
AND THERE'S LARGE INDIVIDUAL
VARIABILITY AND PRESENTATION AND
COURSE CAN THAT'S REALLY SLOWED
THE RESEARCH DOWN IN SOME WAYS
BY NOT UNDERSTANDING AND
REALIZING THAT AND ADDRESSING IT
EMPLOY AND THEN I WILL DESCRIBE
SOME OF THE RESEARCH APPROACHES
THAT ARE BEING TAKEN TO ADDRESS
THIS ISSUE OF VARIABILITY AND
PRESENTATION.
SO 1 THING TO KNOW IS BACK PAIN
IS AN EXTREMELY COMMON SYMPTOM,
IT'S NOT A DEC, IT IS DEFEIGNED
BY LOCATION OF PAIN, SO IT'S
PAIN BETWEEN THE LOWER RIB
MARGIN AND THE GLUTEAL FOLD.
YOU CAN HAVE PAIN IN 1 OR BOTH
LEG ANDS YOU CAN HAVE
NEUROLOGICAL SYMPTOMS ARE NOT.
THE DIAGNOSIS FALL INTOS 2 MAJOR
CATEGORIES, SPECIFIC LOW BACK
PAIN AND NONSPECIFIC LO BACK
PAIN AND THE MA YOURITY OF
PEOPLE, ESTIMATES UP TO 90%
CASES ARE GIVEN THE DIAGNOSIS OF
NONSPECIFIC BACK PAIN AND IS
BECAUSE MOST PEOPLE WHO PREVENT
IN THE CLINIC, THE PAIN
GENERATOR CAN'T BE IDENTIFIED.
SO IN TERMS OF CAUSES OF BACK
PAIN, CLINICAL TESTS ARE NOT
ABLE TO ACCURATELY IEE, AUDIENCE
TENTIFY THE TISSUE SOURCE OF
MOST BACK PAIN.
AND SO IN PARTICULAR, THERE'S
QUITE A BIT OF DEBATE OVER THE
IMPORTANCE OF USING IMAGING THEN
FOR DIAGNOSIS, PARTICULARLY IN
THE CLATIONZ, SO MANY IMAGING
FINDINGS IESHES DENTIFIED IN
PEOPLE WITH BACK PAIN ARE NOT
COMOP IN THOSE WITH NO BACK PAIN
AND THERE'S NO STRONG EVIDENCE
WITH THE FUTURE TO PREDIC LOW
BACK PAIN AND GIVEN THIS, THE
GUIDELINES CURRENTLY
CONSISTENTLY RECOMMEND AGAINST
ROUTINE USE OF IMAGING AT LEAST
INITIALLY EMPLOY SO IN TERMS OF
CAUSES, OR IN TERPS OF HOW FAR
COMMON BACK PAIN IS, IT'S NOT
COMMON IN THE FIRST DECADE OF
LIFE BUT THEN THE PREVALENCE
INCREASES PRETTY STEEP LE DURING
THE TEENAGE YEARS SO 40-NIEPT%
OF THE 18 YEAR-OLDS REPORT
HAVING BACK PAIN, IN ADUTS THE
PREVALENCE IS 37% AND MOST
PEOPLE WILL EXPERIENCE BACK PAIN
AT LEAST ONCE IN A LIFETIME SO
IEWM SURE THAT'S TRUCKS--THEN OF
ALL OF YOU IN THE AUDIENCE, SO
RECURRENCES ARE COMMON, AS YOU
CAN SEE IN THE GROF THE, IT
PEAKS IN MIDLIFE ISSUES IT'S
MORE COMMON IN WOMEN THAN IN MEN
AND THE PREVALENCE OF BACK PAIN
THAT'S ACCOMPANIED BY ACTIVITY
LIMITATIONS SO REHAB KIND OF
FOCUS INCREASES AS PEOPLE AGE.
IN TERMS OF IMPACT, IT HAS
HIGHER CONDITIONS GLOBAL, IT IS
THE LEADING CAUSE OF YEARS LIVED
WITH DISABILITY AND IT IS NUMBER
6 IN DISEASE BURDEN GLOBAL.
TWENTY-EIGHT CASES ARE IN THE
SEVERE LIMITATIONS CATEGORIES
AND THE REMAINDER ARE IN THE
MODERATE TO LOW LIMITATIONS
CATEGORIES, SO THE OVERALL
CENTER FOR EXCELLENCE ON AGING
IS HAY HIGH BURDEN ON SOCIETY.
SO GIVEN BACK PAIN REALLY IS THE
LEADING CAUSE OF DISABILITY
WORLD WIDE, IT'S CLEARLY A
CONDITION WITH A NEED FOR
EFFECTIVE AND EFFICIENT APPROACH
TO TREATMENT.
IMPORTANTLY, MOST CLINICAL
PRACTICE GUIDE LINES CURRENTLY
RECOMMEND NONPHARMAICOLOGICAL
TREATMENT AS PART OF THE FIRST
LINE OF CARE FOR NONSPECIFIC LOW
BACK PAIN AND IN PARTICULAR, THE
EVIDENCE SUPPORTS THE USE OF
EDUCATION IN THE EARLY ACUTE
PHASE AND THEN ADDING EXERCISE
BEYOND THE ACUTE PHASE.
HOWEVER BECAUSE ABOUT 90% OF THE
CASES ARE GIVEN THE DIAGNOSIS OF
NONSPECIFIC BACK PAIN, THE FOCUS
OF MANAGEMENT FOR THE MA YOURITY
OF CASES IS NOT ON A SPECIFIC
PATHOANATOMY OR PATHOPHYSIOLOGY
BUT RATHER IT'SON ALLEVIATING
THE PERSON'S PAIN AND
COUNTERACTING THE ASSOCIATED
DISABILITY AND IN PARTICULAR
TRYING TO AVOID OR MEN MYSELF
THE DEVELOPMENT OF THAT
DISABILITY OR LESSEN IT IF IT'S
ALREADY PRESENT.
SO REALLY IT'S IMPORTANT TO BE
ABLE TO HAVE THE BEST APPROACH
TO RESEARCH AND TREATMENT BY
UNDERSTANDING THE COURSE OF BACK
PAIN.
AND WHAT YOU SEE UP HERE IN THE
UPPER RIGHT HAND CORNER IS A
GRAPH OF WHAT WE THOUGHT WAS THE
COURSE OF NONSPECIFIC BACK PAIN
YEARS AGO AND IT WAS CONSIDERED
TO BE A CONDITION CHARACTERIZED
AS A SERIES OF THESE AKIEWLT
UNRELATED EVENTS THAT WERE
REALLY SHORT LIVED AND THEY
RECOVERED ON THEIR OWN OR YOU
ENDED UP WITH THIS VERY CHRONIC
PROBLEM THAT JUST CONTINUED ON
INDEFINITELY, BUT THE CURRENT
EVIDENT NOW SUPPORTS A RECOVERY
PATERB OF ACUTE BACK PAIN THAT'S
REALLY HIGHLY VARIABLE.
SO STUDIES ANALYZING INDIVIDUAL
PATIENT'S BACK PAIN AND
DISABILITY TRAJECTORIES HAVE
CONSISTENTLY IDENTIFIED THERE
ARE 5 DISTINCT PATTERNS THAT
DIFFER FROM THE POPULATION
AVERAGED COURSE THAT YOU SEE UP
HERE IN THE UPPER RIGHT HAND
CORNER.
SO, WHILE BACK PAIN GOES AWAY,
QUICKLY FOR SOME PEOPLE, SO THE
DATA HERE IN GREEN, UNDER MINOR
RECOVERY, OTHER PEOPLE
EXPERIENCE AN ONGOING COURSE OF
FLUCTUATING PORE CYSTENT BACK
PAIN OF VARYING DEGREES OF
SEVERITY AND THE ESTIMATES FOR
THESE ENCOMPLETE CASES IS AS
HIGH AS 80% OF THE BACK PAIN
CASES AND EVEN IN THOSE WHO
RECOVER, A RECURRENCE WITHIN A
YEAR IS COMMON WITH ESTIMATES
BETWEEN 37 AND 73%.
AND THEY VARIED DEPENDING ON
WHAT THE DEFINITION IS FOR
RECURRENCE.
SO, REALLY THE QUEE QUESTION
THEN BASED ON WHAT I TOLD YOU IS
WHAT ARE THESE VARIABLES THAT
CONTRIBUTE TO DIFFERENT COURSES
AND KNOWLEDGE OF THESE VARIABLES
OR FACTORS WOULD ALLOW DECISIONS
THAT ARE EFFECTIVE ABOUT WHO TO
TREAT, WHEN TO TREAT THEM, HOW
TO TREAT THEM, WHAT TO TREAT AND
HOW MUCH TO TREAT.
SO AS PART OF THIS PROCESS
THERE'S BEEN AN EMPHASIS ON
TRYING TO DEFINE WHO WILL
RECOVER, SO THIS DATA OVER HERE
ON THE LEFT VERSUS WHO WILL HAVE
INCOMPLETE RECOVERY EMPLOY THESE
ARE PEOPLE OFTEN REFERRED TO AS
HAVING CHRONIC OR PERSISTENT LOW
BACK PAIN AND WHO IS GOG HAVE A
RECURRENCE BECAUSE THIS KIND OF
INFORMATION IF IT'S KNOWN AT THE
BEGINNING OF AN EPISODE OR
HAVING BACK PAIN CONDITION COULD
HELP MAKE DECISIONWHERE TO SPEND
RESOURCES.
SO THE CURRENT FRAMEWORK FOR
RESEARCH AND TREATMENT IS
BIOPSYCHOSOCIAL MODEL AND THIS
MODEL PROPOSES THAT MULTIPLE
FACTORS INTERACT TO CONTRIBUTE
TO THE CLINICAL PRESENTATION AND
COURSE OF THE CONDITION.
AND BACK PAIN SYMPTOMS DO,A RISE
FROM NOSICEPTIVE INPUT BUT IT'S
BEING BETTER ACCEPTED, THE
VECTING REPORTS AND RELATED
DISABILITY THAT PEOPLE RECEPT
WITH ARE NOT NEARLY THE RESULT
OF NOSI-ACCEPTION, AND SO YOU
SEE THE CONCEPT AND THESE ARE
THE MAJOR CATEGORIES THAT ARE
PROPOSED TO INFLUENCE THE
PERSON'S PRESENTATION AND
COURSE.
THE BIG CHALLENGE IN TERMS OF
RESEARCH BUT ALSO AT THE
CLINICAL LEVEL IS TO DETERMINE
AT THE INDIVIDUAL LEVEL, THE
RELATIVE IMPORTANCE OF THESE 3
DIFFERENT CATEGORIES OF FACTORS
BECAUSE THAT VARIES FROM 1
PERSON TO THE NEXT.
SO NOW I'M GOING TO HIGHLIGHT
SOME OF THE MOST CONSISTENT KEY
FINDINGS THAT HAD BEEN FOUND
WITHIN EACH OF THE CATEGORIES OF
THE MODEL THAT CONTRIBUTE TO OUR
CURRENT UNDERSTANDING OF BACK
PAIN, AND I WILL START WITH
BIOPHYSICAL FACTORS.
AND SO IF YOU LOOK AT PEOPLE
WITH BACK PAIN COMPARED TO
PEOPLE WITHOUT BACK PAIN, THERE
ARE MULTIPLE BIOPHYSICAL
IMPAIRMENTS THAT HAVE BEEN
IDENTIFY AS DIFFERENT BETWEEN
THE 2 AND I'M GOING TO FOCUS ON
SPECIFICALLY THE MOTOR SYSTEM,
TALKING ABOUT MOTOR CONTROL
IMPAIRMENTS AND MUSCLE STRUCTURE
ALTERATIONS AND THEN I WILL TALK
ABOUT THE SENSORY SYSTEM AND
WHAT DO WE KNOW ABOUT PAIN
PROCESSING IN THESE PEOPLE.
SO FIRST, I WILL TALK ABOUT
MOTOR CONTROL AND MUSCLE
STRUCTURE FINDINGS, AND MOTOR
CONTROL IN THIS CONTEXT IS
REFERRING TO THE WAYS
PEOPLE--WAYS IN WHICH THE
NERVOUS SYSTEM CONTROLS
POSTURING MOVEMENT TO PERFORM A
SPECIFIC MOTOR TASK AND THIS IS
MOST COMMONLY STUDIED IN HUMANS
AT THE LEVEL OF PATTERNS OF
TRUNK MUSCLE ACTIVITY AND TRUNK
MOVE AM ANDS POSTURES AND THE
COMPARISON IS BETWEEN PEOPLE
WITH AND WITHOUT BACK PAIN AND
HAD IS REALLY IMPORTANT BECAUSE
MUSCLE ACTIVATION, MOVEMENT AND
POSTURE CONTRIBUTE TO OPTIMIZING
A PERSON'S SPINAL CONTROL, AND
SO IF ANY OF THESE ARE IMPAIRS
YOUR CONTROL CAN BE DECREASED
AND YOU WILL HAVE A CHANGE IN
TISSUE LOADING.
AND THE RESULT IMMEDIATELY OR
OVERTIME IS THAT THE SPINAL
TISSUE HEALTH IS DIMINISHED AND
THIS IS PROPOSED THEM TO BE THE
REASON WHY PEOPLE DEVELOP BACK
PAIN AND DISABILITY.
SO THE STUDIES OF MOTOR CONTROL
ARE FOCUSED ON TASKS THAT AFFECT
SPINAL LOADING AND THEREFORE
COULD CONTRIBUTE TO INJURY.
AND SO WHAT YOU SEE HERE ON THE
LEFT ARE STUDIES OF MOTOR TASKS
THAT CHALLENGE TRUNK MUSCLES IN
DIFFERENT WAYS AND TRUNK MUSCLE
ACTIVITY IS MEASURED AND THEN
HERE YOU SEE, DIFFERENT STUDIES
THAT LOOK THEA ASPECTS OF TRUNK
POSTURING AND MOVEMENT.
SO PEOPLE WITH BACK PAIN EXHIBIT
A VARIETY OF IMPAIRMENTS OF
MOTOR CONTROL, AND THERE'S HIGH
INTERINDIVIDUAL VARIABILITY, SO
WHAT YOU SEE HERE ON THE LEFT
ARE 3 ACTIVITIES THAT HAVE BEEN
REPORTED ON QUITE A BIT AND THE
FIRST XASMINES TRUNK MUSCLE
ACTIVITY DURING STEADY STATE
POSTURE OF STANDING, THE SECOND
IS 1 WHERE STRUNK MOVEMENT IS
LOOKED AT WITH THE DYNAMIC TASK
OF ELECTRICKING FORWARD AND THE
THIRD IS LOOKING AT ALINEMENT OF
THE PELVIS AND TRUNK AND IN ALL
THESE EXPERIMENTS IS COMPARING
PEOPLE WITH BACK PAIN TO PEOPLE
WITHOUT BACK PAIN.
SO WHAT I'M SHOWING YOU ON THE
RIGHT ARE THE FINDINGS FOR EACH
OF THE ACTIVITIES THAT HAS BEEN
REPORTED IN THE LITERATURE AND
THE FIRST DETAIL TO NOTICE IS
THAT THERE'S A LOT OF
VARIABILITY IN FINDINGS FOR EACH
OF THE ACTIVITIES SO FOR
EXAMPLE, IF YOU LOOK AT MUSCLE
ACTIVITY DURING STANDING BETWEEN
PEOPLE WITH AND WITHOUT LOW BACK
PAIN, YOU WILL SEE THAT SOME
REPORTS INCREASED OTHERS SAY
INCREASED WITH BACK PAIN AND
OTHERS REPORT NO DIFFERENCES
BETWEEN PEOPLE WITH AND WITHOUT
LOW BACK PAIN.
SO IF YOU LOOK DOWN HERE AT
ALIGNMENT OF THE PELVIS AND
TRUNK AND YOU LOOK AT PEOPLE
WITH LOW BACK PEOPLE AS A WHOLE,
COMPARED TO THOSE BACK PAIN,
THERE'S NO DIFFERENCE BETWEEN
THESE 2 GROUPS WITH REGARD TO
ALIGNMENT.
BUT MOTIER --MORE REEBTLY IN THE
LAST 15 YEARS WHAT'S BEEN GOING
ON INCLUDING RESEARCHERS
INCLUDING OUR OWN GROUP HAVE
BEEN SUBTYPING THEM OR
PHENOTYPING THEM BASED ON
MOVEMENT OR PAIN BEHAVIOR, SO
WHEN YOU DO THAT YOU SEE
PRELICATIBLE DIFFERENCES BETWEEN
THE SUBGROUPS BUT ALSO BETWEEN
PEOPLE WHO HAVE BACK PAIN, SNCHT
SUBGROUPS TO THOSE WITHOUT LOW
BACK PAIN.
SO GETTING AT THIS IDEA OF
TRYING TO INTRODUCE THE
INDIVIDUAL VARIABILITY AMONG
PEOPLE WITH BACK PAIN.
SO IN TERMS OF FINDINGS THERE'S
A BROAD ARRAY OF ALTERATIONS OF
PEOPLE WITH BACK PAIN AND ONCE
AGAIN HIGH INDIVIDUAL
VARIABILITY.
THIS IS IMPORTANT BECAUSE THE
ABILITY OF A MUSCLE TO ENMOTOR
COMMANDS DETERMINED HOW GOOD
SOMEONE'S MOTOR CONTROL IS AND
IF YOU HAVE AN ALTERATION IN THE
MUSCLE, IT COULD NEG5 LE IMPACT
MOTOR CONTROL AND I ALREADY
TALKED ABOUT THE CONS QUESTIONSS
OF THAT.
SO STRUCTURAL CHEANCHS ARE BEEN
CONSISTENTLY IDENTIFY INDEED THE
SPINAL MUSCLE ANDS THE POSTERIOR
ASPECT OF THE SPINE AND IN
PARTICULAR IN THE MUSCLE WHICH
IS THE MEDIA MUSCLES, SO THESE
STRUCTURE ALTASD RAYINGINGS HAVE
BEEN LOOKED AT IN HUMANS AS WELL
AS IN ANIMAL STUDIES USING
DIFFERENT INJURY MODELS SO IN
HUMANS THE DATA IS CROSS
SECTIONAL AND POM PAIRS PEOPLE
WITH PAIN TO LOW BACK PAIN AND
OVERALL WHAT'S BEEN DOCUMENT
SIDE THAT THERE'S DECREASED
CROSS SECTION LEVEL IN THE AREA
OF PAIN IN THE ACUTE PHASE AND
IN THE CHRONIC YOU SEE A GREATER
ON PROPORTION OF FAT, INCREASED
FIBROGENESIS AND INCREASED
STIFFNESS IN THE ANIMAL MODEL
STUDIES YOU SEE MOSTLY A DISK
LESION MODEL THAT'S USED, THESE
KINDS OF STUDIES PROVIDE
LONGITUDINAL DAT SOY CAN
UNDERSTAND THE CHANGE IN MUSCLE
OVERTIME, AND ALSO PROBE THE
POTENTIAL MECHANISMS THAT
UNDERLIE THOSE ALTERATIONS.
AND SO OVERALL WHAT YOU SEE IN
THE ACUTE PHASE IS DECREASED
CROSS SECTIONAL AREA IN THE
EARLY CHRONIC PHASE, FATTY
INFILTRATION, FIBROSIS, LOSS OF
1 MUSCLE, POETIC FATIGUE
RESISTANT FIBERS AND THEN IN THE
LATE CHRONIC PHASE MORE MUSCLE
FIBROATROPHY.
SO THESE CHANGES ARE LIKELY TO
BE TIME DEPEND CHENT IS REALLY
IMPORTANT IMPLICATIONS TO
REHABILITATION, THE ANIMAL MODEL
DATA SUGGESTS THAT THE MECH
INFORMS THAT UNDERLIE STRUCTURE
CHANGES DIFFER OVER TIME AND SO
THIS FIGURE ON THE RIGHT IS AN
ILLUSTRATION OF THE DIFFERENCES
IN THE MECHIMISMS OVER TIME
AFTER AN ACUTE DISK LESION AND
YOU SEE INITIALLY THERE'S AN
ACUTE INHIBITOR RESILIENCE
GENERATION PROCESS GOING ON,
THEN THERE'S PRO INFLAMMATORY
CYTOKINE PROCESSES, FOLLOWED BY
THE LAST 9-12 MONTHS, TYPICAL
LOW DISUSE AND DECONDITIONING
PROCESSES.
SO THIS IS IMPORTANT TO REHAB
BECAUSE IT'S BEEN SUGGEST THAD
THE TYPE OF EXERCISE THAT YOU
USE SHOULD BE RELATED TO THESE
TIME RELATED MECHANISMS, SO FOR
EXAMPLE, THE IDEA IS TO USE
MOTOR CONTROL EXERCISE TO
OVERCOME INHIBITION, IN THE
EARLY INHIBITORY REGENERATION
PHASE AND THEN IN THE VERY LATE
PHASE, STRENGTH AND ENDURANCE
TRAINING TO WORK AGAINST THIS
DISUSE AND DECONDITIONING THAT
OCCURS.
SO THE MOST RELEVANT WORK WITH
REGARD TO THE SENSORY SYSTEM IS
THE RECOGNITION, AND PEOPLE WITH
BACK PAIN HAVE DIFFERENT
UNDERLYING MECHANISMS THAT
CONTRIBUTE TO THEIR
PRESENTATION, AND COURSE.
SO ONCE AGAIN VARIABILITY AMONG
INDIVIDUALS.
AND THERE'S 3 BIOLOGICAL PAIN
MECHANISMS TO BE IMPOSED WITH
PEOPLE WITH BACK PAIN, THE FIRST
IS THE NOCI-PAIN MECHANISM,
TRADITIONAL MODEL OF TISSUE
INJURY WHERE PAIN IS DUE TO
ACTIVATION OF NOSI RECEPTORS
THAT BE A RESULT OF
INFLAMMATION, MECHANICAL
INFLAMMATION OR DIRECT INJURY.
YOU ALSO HAVE A PLASTIC PAIN
MECH INFORM, THIS IS 1 IN WHICH
PAIN IS THE RESULT OF ALERATIONS
OF SEBTERAL PAIN PROCESSING,
WHERE YOU SEE INCREASED SEBTERAL
EXCITABILITY, OR DECREASED
CENTRAL INHIBITION OR BOTH.
AND THEN YOU CAN HAVE PEOPLE
WITH LOW BACK PAIN, WHO HAVE
NEUROPATHIC PAIN MECHANISM,
WHERE THERE'S A LESION OR
DISEASE WITHIN THE SOPHISTICATED
MAT O SENSORY SYSTEM, AND IMEAN
GOING BACK TO THIS IDEA, OF
INTERINDIVIDUAL VARIABILITY,
PEOPLE WITH LOW BACK PAIN CAN
HAVE 1 OR ANY COMBINATION OF
THESE PAIN MECHANISMS.
SO THERE IS WORK ONGOING TO
IMPROVE THE IDEPTICTION OF
MECHANISMS IN PEOPLE WITH BACK
PAIN AND THE IDEA IS CAN YOU
PHENOTYPE PEOPLE AND THE BIGGEST
CHALLENGE IN HUMAN SYSTEM THAT
THE IDENTIFICATION IS LIMITED TO
VERY INDIRECT METHODS SO WE CAN
USE PATIENT HISTORY,
QUESTIONNAIRES AND MORE RECENTLY
QUANTITATIVE SENSORY TESTING
WHICH IS CONSISTS OF THESE
STANDARDIZED PSYCHOTESTS WHERE
THEY'RE INTRODUCED TO TRY AND
IDENTIFY WHETHER OR NOT THE PAIN
PROCESSING IS ALTERED.
BUT THERE ARE LIMITATIONS
CURRENTLY TO THE TESTING, THERE
IS A LACK OF CONSENSUSOT TEST,
THE TEST METRICS ARE NOT FULLY
ESTABLISHED AND THERE'S A LACK
OF NORMATIVE VALUES, AND THESE
METHODS REALLY ARE NOT
CLENICALLY FEASIBLE TO USE AT
THIS POINT IN TIME.
SO PSYCHOLOGICAL FACTORS ARE
LOOKED AT BECAUSE PAIN IS
DEFINED AS BOTH A SENSORY AND AN
CERTAINLY--CERTAINLY MOTIONAL
EXPERIENCE.
AND SO THE PRIMARY INTEREST IN
PSYCHOLOGICAL FACTORS AND PEOPLE
WITH BACK PAIN IS THEIR ROLE IN
ACUTE TO CHRONIC TRANSITION,
THEIR IMPACT ON THE LONG-TERM
COURSE OF BACK PAIN, AND IT
THEIR IMPACT OF TREATMENT
CHRONIC LOW BACK PAIN AND THERE
ARE THE--2 CATEGORIES OF FACTORS
THAT HAVE BEEN LOOKED AT IN THE
LITERATURE AND THE FIRST IS
GENERAL PSYCHOLOGICAL FACTORS
AND THESE ARE FACTORS THAT ARE
NOT UNIQUE TO PEOPLE WITH BACK
PAIN, AND INCLUDE DEPRESSION,
TRAIT ANXIETY AND EMOTIONAL
DISTRESS, THE SECOND CATEGORIES
OF FACTORS ARE PAIN SPECIFIC
FACTORS, THESE ARE FACTORS THAT
ARE UNIQUE TO PEOPLE WITH PAIN,
AND THEY'RE SEPARATED INTO 2
CATEGORIES, NEGATIVE MOOD AND
FEAR FACTORS, THESE ARE PROPOSED
TO BE RISK FACTORS FOR THAT
INCOMPLETE RECOVERY, AND THEN
YOU HAVE POSITIVE AFFECT IN
COPING FACTORS AND THESE ARE
SUPPOSED TO BE PROTECTIVE
FACTORS FOR COMPLETE RECOVERY OR
LONG-TERM DISABLE.
SO IN TERMS OF GENERAL
PSYCHOLOGICAL FACTORS PREMORBID
PSYCHOLOGICAL DYSFUNCTION CAN BE
A RISK FACTOR FOR FUTURE LOW
BACK PAIN.
WE ALSO KNOW THAT THESE FACTORS
ARE ELEVATED IN PEOPLE WITH
CHRONIC BACK PAIN WHEN YOU
COMPARE THEM TO PEOPLE WITHOUT
BACK PAIN SUGGEST THRG ARE
CONSEQUENCE OF HAVING CHRONIC
LOW BACK PAIN.
AND THEY ALSO HAVE PROGNOSTIC
VALUE.
SOME OF THEM CAN PREDICT THE
LIKELIHOOD OF THE ACUTE TO
CHRONIC BACK PAIN TRANSITION AND
THEY'RE ASSOCIATED WITH THE
OUTCOMES OF BACK PAIN SUCH AS
PHYSICAL, WORK DISABLE, AMOUNT
OF HEALTHCARE COSTS AS WELL AS
MORTALITY.
SO PAIN SPECIFIC FACTORS SO
NEGATIVE MOOD AND FEAR HAVE BEEN
FOUND TO BE RISK FACTORS FOR THE
DEVELOPMENT OF LOW BACK PAIN SO
GOING ON TO THE LONG-TERM
COURSE.
THERE ARE ALSO PROGNOSTIC AND
THERE ARE ASSOCIATE WIDE
MULTIPLE OUTCOMES SUCH AS LEVEL
OF RETURN TO WORK, LEVEL OF PAIN
INTENSITY, INTOLERANCE AS WELL
AS RISK FOR OPIOID MISUSE.
IN TERMS OF POSITIVE EFFECTIVE
COPING, SELF-EFFICACY HAS BEEN
FOUND TO MEDIATE CHANGE IN MAIN,
PLEASNESS AND PHYSICAL
DISABILITY OVER A 1 YORE COURSE
AND ACTIVE PAIN COPING AS BEEN
ASSOCIATE WIDE PAIN RELATED
INTERFERENCE WITH LONG-TERM
FOLLOW UP EMPLOY SO THERE ARE
CHALLENGES IN STUDYING
PSYCHOLOGICAL FACTORS AND LOW
PACK PAIN AS I ALREADY HAVE
SHOWN YOU, THERE ARE A LARGE
NUMBER OF FACTORS, THERE ARE
IRPT CORRELATED VARYING DETBREES
AND THERE'S NO 1 FACTOR THAT'S
BEEN FOUND TO BE MORE IMPORTANT
THAN ANOTHER.
AND REEBT DATA SUGGIESTS THAT
ELEVATED SCORES ON A GREATER
NUMBER OF VARIABLES IS WHAT'S
PREDICTIVE OF THE DEVELOPMENT OF
PERSISTENT PAIN AND DISABILITY
AND GIVEN THIS RECOMMENDATION,
AND THE USE OF CUMULATIVE GLOBAL
RISK INDICES, RATHER THAN
FOCUSING ON THE INDIVIDUAL
PSYCHOLOGICAL FACTORS.
SO FEIGNALLY SOCIAL FACTORS
THESE ARE EXTERNAL FACTS OR
CIRCUMSTANCES THAT INFLUENCE A
PERSON'S BEHAVIORS AND ADITUTES
RELATED TO THEIR PACK PAIN.
AND A RECENT STUDY DOCUM THAD
COMPARED TO THE WO, THAT'S BEEN
DONE IN THE BIOPHYSICAL AND
PSYCHOLOGICAL SPACE, THERE'S FAR
FEWER STUDIES THAT HAVE
ADEQUATELY EXAMINED SOCIAL
FACTORS IN BACK PAIN EMPLOY
IMIVEN THIS THERE ARE A NUMBER
OF SOCIAL FACTORS THAT HAVE BEEN
HYPOTHESIZED TO BACK PAIN AND
IT'S RELATED DISABILITY AND HERE
CAN YOU SEE THAT THERE'S 4
CATEGORIES, THE FIRST IS SOCIAL
DISADVANTAGED, THE NEXT IS
SOCIAL FACTORS RELATED TO WORK
ENVIRONMENT, SOCIAL FACTORS
RELATED TO THE CLINICAL
EXPERIENCE WITH TREATMENT AND
ARK ASSESSESMENT, AND THEN
SOCIAL FACTORS RELATED TO THE
HOME ENVIRONMENT.
AND SO IN TERMS OF WHAT WE KNOW
ABOUT THESE SOCIAL FACTORS AND
BACK PAIN, THERE IS AN INCREASED
RISK OF LOW PACK PAIN INITIAL
DEVELOPMENT AS WELL AS RICK OF
RECURRENCE WHICH IS COMMON IN
BACK PAIN, AND THIS IS TRUE FOR
PEOPLE WITH REGARD TO WORK WHO
HAVE WORK EXPENSURES, OF
LIFTING, BENDING AND AWKWARD
POSTURES AS WELL AS HEAVY WORK
AND DEMANDING WORK AS WELL AS
PEOPLE WHO HAVE JOB
DISSATISFACTION AND LOW JOB
CONTROL.
THESE FACTORS HAVE HAVE ALSO
BEEN FOUND TO BE PROGNOSTIC SO
LOW INCOME, LOW SOCIAL SUPPORT,
AT WORK AND OUTSIDE OF WORK HAVE
BEEN ASSOCIATE WIDE PROGNOSIS
FOR INDOMAIN PLETE RECOVERY OR
PERSISTENT BACK PAIN AND
DISABILITY.
SO WHAT ARE THE CHALLENGES
MOVING REHABILATION RESEARCH FOR
WITH REGARD TO LOW BACK PAIN.
AS I TOLD YOU MOST CLINICAL
PRACTICE GUIDELINES SUPPORT
NONFARM ON CO LONGICAL TREATMENT
AS PART OF FIRST LINE CARE
PARTICULARLY AFTER THE ACUTE
PHASE.
IMPORTANTLY THOUGH, THERE IS AN
EMPHASIS IN THE ACUTE PHASE OF
RESUMING FUNCTION AND
PARTICIPATION AS QUICKLY AS
POSSIBLE, SO VERY MUCH REHAB
GOALS, REHAB GOALS.
UNFORTUNATELY TO DATE MOST REHAB
TREATMENTS FOR BACK PAIN,
PARTICULARLY THOSE THAT ARE
ACTIVITY AND EXERCISE BASED,
WHEN YOU COMPARE 1 TREATMENT TO
ANOTHER, HAVE RESULTED IN ONLY
VERY SMALL, TO MODERATE EFFECT
SIDES AT BEST AND THE EFFECTS OF
SHORT-TERM WHICH IS NOT GOOD FOR
A CONDITION THAT FOR MANY PEOPLE
HAS A LONG TIME COURSE.
AND THE EXPLANATION FOR THESE
RESULTS IS HIGH INDIVIDUAL
VARIABILITY THAT IS PROPOSED TO
BE ATTENUATING TREATMENT EFFECTS
BECAUSE THEY'RE NOT AS TARGETED
AS THEY AS THEY NEED TO BE.
THE PROPOSAL IS TO SUBGROUP OR
PHENOTYPE PEOPLE BASED ON THEIR
SUSCEPTIBILITY TO THEIR BACK
PAIN, BIOLOGY, PROGNOSIS OR
RESPONSE TO TREATMENT WITH THE
IDEA THAT THIS WILL ALLOW BETTER
TAILORING OF TREATMENT TO
INDIVIDUAL CHARACTERISTICS.
SO THERE ARE 2 RESEARCH
APPROACHES THAT ARE CURRENTLY
BEING EXAMINED AND TESTED IN LOW
BACK PAIN, FOLLOWING THIS MODEL,
THE FIRST IS TO PHENOTYPE OR
SUBGROUP PEOPLE BASED ON THOSE
FACTORS THAT I JUST TALKED
ABOUT, SUCH AS MOTOR CONTROL
FACTORS, POSTURE MOVEMENT AND
PAIN, OR PAIN MECHANISMS, AND
THERE ARE A NUMBER OF STUDIES
THAT HAVE BEEN CONDUCTED, EACH
ARE AT DIFFERENT STAGES OF
INQUIRY, USING THIS APPROACH AND
THESE HAVE HAD SOME PRETTY
PROMISING RESULTS, THE OTHER IS
THAT'S BEEN PROPOSE SIDE TO
DEVELOP AND TEST
MULTIDIMENSIONAL CLINICAL
REASONING ALGORITHMS WHERE
THEREYA A BROAD ARRAY OF FACTORS
THAT ARE ASSESSED AND WEIGHTED
TYPICALLY USING CLINICIAN
JUDGMENT AND THEN THAT
INFORMATION IS USED TO
INDIVIDUALIZE THE TREATMENT AND
THERE WAS RECENTLY A STUDY THAT
WAS PUBLISH FRIDAY AUSTRALIA
WHERE IT WAS A CLINICAL TRIAL,
WHERE THEY TESTED A ALGORITHM
AND ALSO REPORTED PROMISING
RESULTS.
SO WHAT I'VE TOLD YOU IS THAT
BACK PAIN IS A COMPLEX
CONDITION, MOST PEOPLE ARE GIVEN
THE DIAGNOSIS OF NONSPECIFIC
BACK PAIN AND THAT'S THE
MAIORITY OF CASES YOU SEE IN
REHABILITATION EMPLOY IT'S
UNDERSTOOD AS A VERY LONG
LASTING CONDITION WITH A
VARIABLE COURSE RATHER THAN THE
SHORT-TERM VERY UNRELATED
EVENTS.
THE CURRENT FRAMEWORK FOR
RESEARCH AS WELL AS TREATMENT IS
THE BIOPSYCHOSOCIAL MODEL, AND
RESEARCH AND LOW BACK PAIN IS
HOPEFULLY MOVING TOWARDS MORE
PRECISION MODEL TO BETTER
INDIVIDUALIZED TREATMENT AND
THIS IS JUST TO ACKNOWLEDGE OUR
FUNDING FROM NIH, PARTICULARLY
THE NCMRR THAT HAS SUPPORTED OUR
WORK AND OUR TRAINEES OVER THE
YEARS AND THANK YOU FOR YOUR
ATTENTION AND I'M HAPPY TO TAKE
ANY QUESTIONS.
>> THANK YOU SO MUCH.
WE'RE OPEN FOR QUESTIONS.
YES, KATHLEEN?
>> FIRST OF ALL THANK YOU FOR A
REAL, REALLY INTERESTING TALK
GOOD TO SEE YOU.
ALSO I'M CURIOUS, YOU DIDN'T
MENTION, I FEEL LIKE I HAVE TO
ELECTRIC AT YOU THIS WAY, I'M
CURIOUS YOU DIDN'T REALLY
MENTION THE USE OF WEARABLE
TOOLS OR DIGITAL TOOLS TO HELP
WITH THIS RESEARCH AND THAT
BEING DONE OR NOT REALLY
ADVANCED ENOUGH TO BE HELPFUL IN
THIS PARTICULAR CASE IN.
>> YEAH, GREAT QUESTION.
IT'S NOT BEEN EXPLORE AS MUCH AS
IT HAS IN THE NEUROLOGICAL
CONDITION WORLD, BUT IT IS BEING
EXPLORED AND THERE'S SOME WORK
BEING DONE AT STANFORD THERE'S
ACTUALLY A WEARABLE SENSOR
TECHNOLOGY GROUP THAT'S DOING
WORK, THEY'RE MOSTLY LOOKING AT
ACTIVITY LEVELS AND WE'RE
CURRENTLY COLLABORATING WITH
THEM BECAUSE WE'RE LOOKING AT
ACTIVITY LEVELS IN ACUTE LOW
BACK PAIN.
IF YOU LOOK--IT'S VERY HARD WITH
WEARABLES TO MEASURE THE KINDS
OF VARIABLES THAT I WAS TALKING
ABOUT, LIKE HOW DO YOU MOVE,
RIGHT, OR WHAT ARE THE POSTURES
YOU ASSUME?
SO THAT'S BEEN A LIMITATION.
PEOPLE ARE WORKING ON IT, PEOPLE
ARE TRYING TO PUSH IT FORWARD
FASTER THAN I THINK IT SHOULD BE
BEFORE YOU'RE CONFIDENT OF WHAT
YOU'RE GETTING.
BUT WELL IS SOME INTERESTING
WORK GOING ON IN SAN DIEGO
STATE, SARAH GAMBATO IS DOING
SOME OF THAT WORK, SHE WORKED
WITH US EMPLOY PAUL HODGES IN
AUSTRALIA, IS DOING SOME OF THAT
WORK AND AGAIN PEOPLE AT
STANFORD.
>> OTHER THOUGHTS, QUESTIONS IN
MICHELLE?
>> HELLO.
>> THANK YOU FOR THE TALK.
IT WAS REALLY INTERESTING, I
WILL KEEP IN MIGHT BE AS AN
ENGINEER, I NOTICED THAT THERE'S
A LOT MORE NIH CALLS AND 1 OF
THEM WAS TALKING A LITTLE BIT
ABOUT TECHNOLOGY TO ACTUALLY
HELP WITH THE TREATMENT FOR BACK
PAIN AND I HAD A POST DOC
STUDENT THAT WAS TALKING ABOUT
DEVELOPING LIKE INTIMATE MASSAGE
KIND OF LIKE PLAYING WITH THE
MASSAGE PROCESSES FOR LOW BACK
PAIN AND I WAS JUST CURIOUS HAS
TO IN YOUR RESEARCH, AND LOOKING
AT THE WORK HAVE YOU COME ACROSS
ANY OF THOSE TYPES OF THOUGHTS
ABOUT USING TECHNOLOGY OR
DEVELOPING TECHNOLOGY TO TREAT
OR TO ADMINISTER, YOU KNOW MAYBE
MASSAGE TREATMENT OR ET CETERA?
>> YEAH, YEAH, THAT'S AN
INTERESTING QUESTION.
WE ARE NOT OURSELVES IN THIS
SPACE OF TECHNOLOGY PER SE FOR
TREATMENT.
A LOT OF WHAT'S BEEN SEEN IN THE
LITERATURE IN TERMS OF KIND OF
PASSIVE TREATMENTS WHICH MASSAGE
WOULD BE VERSUS ACTIVE, IS THAT
WE SHOULD BE MOVING TOWARDS
ACTIVE TREATMENTS.
YOU ALSO HAVE AN ADHERENCE
ISSUE, YOU GIVE SOMEBODY
TECHNOLOGY, YOU HAVE ISSUES OF
UNDERSTANDING HOW TO USE IT
ACCURATELY AND IF YOU CAN, ARE
THEY GOING TO DO ENOUGH TO GET A
THERAPEUTIC EFFECT OR LONG
LASTING EFFECT AND I THINK
THAT'S TRUE, WHETHER YOU TALK
ABOUT TECHNOLOGY OR ACTIVE KINDS
OF TREATMENT, SO THE THINGS THAT
WE DO, ARE REALLY FOCUSED ON
CHANGING MOVEMENT BEHAVIOR
DURING FUNCTION BECAUSE THEN
THEY CAN PRACTICE IT ACROSS
THEIR DAY AND IT FACILITATES
THEIR ADHERENCE BUT THAT'S MY
BIAS.
>> OTHER QUESTIONS?
SARAH IN?
>> HI, THANK YOU FOR A VERY
INTERESTING TALK.
ONE OF MY AREAS OF RESEARCH IS
LOOKING AT CARE GIVING IN STROKE
AND SO I WAS STRUCK BY THE SLIDE
YOU MENTIONED SOCIAL FACTORS IN
HOME, AND SO, NOT ONLY I THINK
THE ROLE OF CARE GIVING BUT ALSO
FAMILY CONFLICK AND HOW THAT MAY
IMPACT, CAN YOU SPEAK A BIT MORE
IT TO THAT WORK IN.
>> YEAH, I CAN TALK NOT
SPECIFICALLY ABOUT THAT PER SE,
BUT THIS IDEA OF TRAUMA AND
CONFLICT DEFINITELY HAS A
NEGATIVE IMPACT ON THE ABILITY
OF PEOPLE TO REALLY ENGAGE THIS
REHAB AND FOLLOW THROUGH IN
REHAB AND SO PEOPLE WHO HAVE
CONFLICT AT HOME AND/OR HAVE HAD
TRAUMA ARE ALSO MORE SUSCEPTIBLE
TO THE DEVELOPMENT OF LOW BACK
PAIN IN PARTICULAR CHILDHOOD
TRAUMA.
THE DATA'S BEEN COMING OUT IN
THE LAST 5 YEARS SUGGESTING
THAT, SO THINGS THAT I WOULD
NEVER HAVE THOUGHT ABOUT, YOU
KNOW WHEN I STARTED IN THIS
AREA.
DOES THAT ANSWER YOUR QUESTION
IN
>> YES, YES.
SO I THINK TO ME AND ALSO IT
UNDERSCORES AN OPPORTUNITY WHEN
YOU'RE DOING EVALUATION OF THE
PATIENT, DO AN
CERTAINLY--CERTAINLY VALUATION
OF FAMILY AS WELL.
AND THOSE FACTORS AND HOW ALL
THAT MAY IMPACT YOUR CARE.
>> YEAH, WE'VE DONE A LOT OF
WORK IN ADHERENCE AND THIS IDEA
OF HAVING PEOPLE WHO ENCOURAGE
YOU TO DO WHAT YOU'RE SUPPOSED
TO DO IS SUPER IMPORTANT.
>> ONE LAST QUESTION FOR
MICHELLE?
>> YEAH, YOU MENTIONED ABOUT,
YOU KNOW MAYBE THERE'S NO 1 TYPE
OF CLINICAL ASSESSMENT TOOL.
HAS ANYONE BEGUN TO KIND OF COME
UP WITH THE NEUROPSYCHOLOGICAL
BATTERY LIKE THEY DO FOR
COGNITIVE PRESENTATIONS FOR ARK
ASSESSING HIV, NEURODISORDERS,
JUST KIND OF LIKE A GROUP OF
BEST PRACTICES, LOOK AT THESE
TESTS AND THESE TESTS AND THEN
THE GROUP TOGETHER MIGHT GIVE
YOU SOME INSIGHT?
>> YEAH, THATIA JUST A REALLY
IMPORTANT QUESTION NOT ONLY IN
THE PSYCHOLOGICAL REALM BUT
ACROSS THE BOARD.
HOW DO WE REDUCE THE NUMBER OF
TESTS THAT ARE KEY TO PROBING
WHAT WE WANT TO PROBE IN EACH OF
THOSE BIOPHYSICAL, PSYCHOLOGICAL
AND SOCIAL, IN THE PSYCHOLOGICAL
REALM THIS IS INTERESTING WORK I
WANTED TO TALK ABOUT BECAUSE OF
TIME I DIDN'T, THERE IS A
MEASURE THAT'S LACKING AT
PSYCHOLOGICAL AND SOCIAL FACTORS
LOOKING AT BOTH KIND OF THESE
NEGATIVE RISK FACTORS FOR
PROCEEDING NOSEIS VERSUS ALSO
THESE POSITIVE FACTORS, THINGS
THAT ARE PROTECTIVE, IT'S CALLED
THE OSPRO, I DON'T REMEMBER WHAT
THAT ACRONYM STANDS FOR RIGHT
FOURTH APPEARANCE BTS IT'S WORK
BEING DONE AT DUKE UNIVERSITY
AND THEY HAVE COME UP WITH, IT'S
A DOWN TO AN 11 ITEM SCREENING
TOOL THAT ACTUALLY EVENT WHEN
YOU CONTROL FOR OTHER FACTORS
HELPS TO PREDICT HOW SOMEONE'S
GOING TO DO LONG-TERM, LIKE OUT
TO 12 MONTHS.
AND THAT'S THE EXTENT OF WHAT I
KNOW ABOUT IT.
WE'RE USING IT NOW IN A CROSS
SECTIONAL STUDY.
SO THERE IS GOOD WORK BEING DONE
AND THEY HAVE BEEN WORKING ON
THIS FOR 6 OR 7 YEARS NOW.
>> THANK YOU.
THANK YOU DR. VAN DILLEN AND
THANK TO YOU EACH OF THE
SPEAKERS THIS MORNING FOR
KEEPING THINGS ACTIVE AND
ENGAGED.
THANK YOU.
>> THANK YOU.
>> AND NOW WE WILL NOW MOVE TO
THINKING ABOUT THE--SORRY.
OKAY.
SO WE'RE NOW AT THE POINT WE'RE
GOING TO BE LOOKING FORWARD TO
MAY AND TOPICS WE MIGHT WANT TO
INCLUDE AND STEVE IS FIRST IN
LINE.
NTHANKS, BARBARA, A LITTLE BIT
OF A DIFFERENT TANGENT.
THE LAST 3 SPEAKERS THIS OTHER
THAN MODEL CITIZENNING DID A
REALLY GOOD JOB OF PROVIDING AN
OVERVIEW, EXCUSE ME, OF THEIR
TOPIC AREA BUT I WAS REMINDED AS
I WAS LISTENING THROUGH THIS AND
IF WE ARE AN ADVISORY GROUP,IME
NOT SURE I CAME AWAY WITH OR
THERE WAS SOME THERE BUT CLEARLY
WHAT STEPS CAN WE DO AS AN
ADVISORY GROUP OR HOW DOES THE
BORD AS AN ADVISORY GROUP SEE
THE GAPS PRIORITIZE THE GAPS,
DECIDE TO EITHER ANNOUNCE FOR
INTERESTING GAPS OR FUN GAPS
THAT ARE THERE, AGAIN ALL THE
TOPICS GAVE ME A GREAT OVERVIEW
OF THE CHALLENGES THEY HAVE AND
THE WORK THEY'VE DONE BUT I'M
WANTING A LITTLE BIT TO BETTER
UNDERSTAND HOW CAN WE BEST HELP
THEM IN TERMS OF THIS IS WHERE
FUNDING IS OR NOT IS, AND THIS
IS WHERE WE NEED TO PRIORITIZE.
WHAT INFORMATION DO WE NEED TO
DO TO GET THERE AND WHAT
PROCESSES DID THE BOARD HAVE TO
HELP US FIGHT THROUGH IT?
>> THANKS STEVE, BECAUSE I
THOUGHT YOU MIGHT ASK A QUESTION
LIKE THIS, AND I WANTED TO DO
BACKGROUND AND SAY WELL, HERE'S
THE RESEARCH FUNDING FOR THE
TOPICS AND WE DON'T TRACK
INJURY.
MCRUCIATE LIGAMENT SCULOSKELETAL
INJURY, SO I THOUGHT WOW, WE
DON'T BE ABLE TO DO THAT MUCH SO
NIH NEEDS TO DO A LITTLE BIT
MORE WORK TO GIVE YOU SOME OF
THAT INFORMATION.
BUT PART OF THE BOARD'S ROLE IS
TO PUT THINGS OUT THERE FOR
INVESTIGATOR INITTIAITED IDEAS
SO I HEARD A HUNDRED RO-1S THIS
MORNING THAT PEOPLE COULD PUT
TOGETHER AND SEND IN, YOU KNOW
WHEN I TALKED ABOUT THE
INCREDIBLE GROWTH IN THE REHAB
PORTFOLIO, THAT WASN'T BECAUSE
WE PUT OUT ANNOUNCEMENTS SAYING
WE NEED THIS RESEARCH, IT WAS
BECAUSE THE FIELD DID THAT.
SO I THINK WE'RE ALREADY IN A
LITTLE WAY, DOING WHAT YOU'RE
ASKING BY HAVING THESE MEETINGS
AND PUTTING IT OUT THERE AND
LETTING PEOPLE KNOW THAT THESE
ARE ISSUES IN THE FIELD.
SO I'M NOT ANSWERING YOUR
QUESTION EXACTLY,--YEAH, GO
AHEAD.
>> THAT HELPS, I GUESS.
SO WE REALLY IN TERPS OF A FEET
FORWARD MECHANISM, WEB CONNECTED
DON'T NECESSARILY PROVIDE A
DOCUMENT OR CIRCULATE MATERIAL
TO SAY THIS IS WHAT WE'VE HEARD
AND INDEPENDENT INVESTIGATORS
WHO LIVE IN THIS SPACE, THESE
ARE NEEDS, THESE ARE NOT NEEDS,
ET CETERA.
WE LET THE--IT HAPPENS
ORGANICALLY IS THE BEST WAY TO
PUT IT.
>> WELL, THERE'S 2 WAYS.
SO, YOU ALREADY VOLUNTEERED TO
HELP WITH THE RESEARCH PLAN, SO
THAT'S A GOOD WAY TO SAY, HEY
GUYS, THESE ARE AREAS THAT ARE
READY AND RIPE FOR RESEARCH
APPLICATIONS, SO THAT WOULD BE
THE DOCUMENT, AND THEN THE OTHER
IS THESE DISCUSSIONS AND RALPH
LIKES TO SAY, WE EXPECT YOU GUYS
TO GO BACK TO YOUR COMMUNITY
ANDS SAY, YOU KNOW I HEARD THIS
REALLY GREAT TALK AND MAYBE WE
SHOULD DIG INTO THIS.
SO IT'S A FEW WAYS THAT WE COULD
DO IT.
>> AND STEE FEN, I WANTED TO ADD
THERE ARE ISSUES OUT THERE AND
SOMETIMES PEOPLE ARE AWARE OF
THESE ISSUES AND PUTTING IN THE
RIGHT APPLICATIONS AND STEVE
GAVE A GOOD EXAMPLE OF HOW THE
D.O.D. CULTURE AND VA ARE ALL
OVER AND THE GREAT PARTNERS AND
THEY HAVE SOME UNIQUE ANGLES AND
HOW YOU DEAL WITH IT THE ACUTE
AND IN THE BATTLEFIELD SENSE.
I THINK WE GO BACK TO THE FIRST
TALK TODAY BUT WE HAVE A SENSE
FROM FLORA HOW THE DIFFERENCE
BETWEEN SHORT-TERM ACUTE CARE
AND THE LACK OF LONG-TERM
COMMITMENT AND IN AS MUCH AS OUR
COLLEAGUES IS AWARE OF THESE
THINGS IS THERE A NEED TO
HIGHLIGHT THEM OR A NEED TO
INCENTIVIZE SOME BEHAVIOR, SOME
NEED FOR US TO SET UP A
CENTRALIZED INFRASTRUCTURE TO
FACILITATE THE RESEARCH, SO YOU
KNOW HELPING US UNDERSTAND WHERE
OUR BLIND SPOTS.
THE FIELD IS ALREADY VERY GOOD
AT SELF-IDENTIFYING AND IT'S
JUST A MATTER OF SOMETIMES THERE
ISN'T A BREAK THROUGH AND WE
KIND OF LEAVE IT FOR THAT BUT IN
AS MUCH AS WE'RE KIND OF
INRIGHTING YOU TO OUR SIDE SO
YOU GET TO SEE THESE THING ANDS
IN AS MUCH AS YOU CAN IDENTIFY
WHERE DOES SOMETHING WE REALLY
HAVE TO INTERVENE SPEAK UP,
THAT'S YOUR ROLE.
>> YEAH, I WAS THINKING
SOMETHING THAT I THINK AIAN LOT
IS HOW DO WE--IT WOULD BE NICE
TO MAYBE SOME SOME EXAMPLES OF
THIS, THAT'S WHY I'M BRINGING IT
UP, OF PEOPLE THAT HAVE
SUCCESSFULLY INTORPERATED
MECHANISTIC WORK AND
REHABILITATION TOGETHER, NOT
AS--MY WORRY IS THAT WE SAY THAT
AND WE GET PEOPLE WHO ARE BASIC
SCIENTISTS AND THEN ENCLUED THE
EDSS, AND SHAY THEY NOW SPANNED
THAT SPECTRUM AND THEY HAVEN'T,
RIGHT?
OR THE REHABILITATION WORK THAT
DOESN'T INCORPORATE MECHANISTIC
WORK, BUT SOMEHOW, I DON'T THINK
IT'S GOING TO BE AS SIMPLE AS
JUST BRIDGING THIS GAP BUT AT
LEAST STUDIES THAT HAVE BEEN
SUCCESSFUL IN TRYING TO DO THAT
MIGHT BE REALLY HELPFUL TO THE
FIELD.
>> THANK YOU EMPLOY IT MIGHT BE
CAREERS, NOT JUST STUDIES, BUT
YEAH.
NCHRIS, THANK YOU.
NTHANKS, SO IT WAS BEING THE
SESSION, WE HEARD A LITTLE BIT
FROM THE VA, WE HEARD A BIT
ABOUT D.O.D. PERSPECTIVE ON
REHABILITATION AND I'M WONDERING
IF THE GROUP IS INTERESTED IN
HEARING FROM THE ARP A-H GROUP
ABOUT THE ROLE OF REHABILITATION
IN THAT AGENCY
EN--STRATEGIESITUTE, WHATEVER
THAT WORD IS.
IT'S DIFFERENT.
>> DAWN IN N2 IDEAS 1 IN
RESPONSE TO CATHY'S I WAS JUST
THINK BEING A COLLEAGUE MARK
JENSEN SOME OF YOU MAY KNOW A
PINE PSYCHOLOGIST WITH LOTS OF
FUNDING FROM NIH, PAIN
REHABILITATION AND HE HAS DONE A
NICE JOB OF INTEGRATING
PSYCHOSOCIAL MECHANISMS THAT AT
LEAST IN SOME BRAIN MECHANISMS
INTO BANE, RESEARCH AND THE
CONTEXT OF CLINICAL TRIALS,
FUNDED BY NCI,--NCCIH, WHERE THE
PRIMARY CAN'T BE THE EFFICACY,
THAT HAS TO BE A SECONDARY HAIM
AND THE PRIMEY IS MECHANISMS
SOPHISTICATED I THINK HE'S HAD
YEARS OF EXPERIENCE WITH
MECHANISMS IN PSYCHOLOGY OF PAIN
AND MAYBE THERE WOULD BE
TRANSLATION TO OTHERS.
THAT'S 1 TOPIC.
JUST ANOTHER TOPIC, I THOUGHT
WAS WAS JUST MANY OF US IN THE
TRAINING GROUP TALKED ABOUT
MENTORS AND
M-TEBURKEULOSEISORRING AND I
DON'T KNOW WHAT I'M SUGGESTING
HERE BUT SOME THEME OF
MENTORING
SCIENTISTSENTIOUS SPECIALLY
THOSE IN UNDERREPRESENT
COMMUNITIES HOWY CAN WE TALK
ABOUT THAT HERE, DO MORE TO
PROMOTE THEIR CAREERS BEYOND THE
TRAIPING AND MECHANISMS THAT
ALREADY EXIST?
>> LEWIS?
>> YEAH, ACTUALLY 1 OF THE
THOUGHTS I HAD WAS SIMILAR TO
THAT PREVIOUS COMMENT SO THAT'S
REALLY REALLY GREAT EMPLOY I HAD
A COUPLE THINGS WRITTEN BOW I
WON'T GO THROUGH ALL OF THEM BUT
1 THAT REALLY RANG OUT TO ME A
LITTLE BIT PARTICULARLY FROM
JAIM'S TALK AND FROM SOME OF THE
OTHERS AS WELL IS IN THE CASE OF
LIMB LOSS WITH PROSTHESIS THERE,
'S A BIG DISTRICT ATTORNEY WHERE
THERE'S A SEA OF THING, SO MANY
TOOLS, TECHNIQUES,A PROACHS, YOU
KNOW FROM A RESEARCH, PURELY
RESEARCH PERSPECTIVE, SOMETIMES
IT CAN BE DIFFICULT TO REALLY
UNDERSTAND, YOU KNOW HOW TO
MERGE THINGS TOGETHER, HOW TO
YOU KNOW MOVE THINGS FORWARD,
HOW TO PRUNE AWAY THINGS WE
SHOULDN'T BE DOING AND SEEING
GOOD MODELS OF WHAT THAT LOOKS
LIKE, SEEING REALLY GOOD MODELS
MAY BE OF HOW TECHNOLOGIES HAVE
COME ON BOARD AND HAVE BEEN SUN
SETTED BECAUSE OF BASIC SCIENCE
INVESTIGATION, MECHANISTIC
INVESTIGATION INTO THOSE THINGS,
AND HOW WE CAN COULD BE DOING
THAT MORE.
ANOTHER IDEA, THIS IS HAS COME
UP BECAUSE I'VE HEARD THE PHRASE
WHICH I'M ALWAYS EXCITED TO
HEAR, SOCIAL DETERMINANTS OF
HEALTH IN THINKING A LOT MORE
ABOUT MAYBE HOW THAT CAN HELP US
UNDERSTAND THE PRECISION
MEDICINE AND REHABILITATION,
RIGHT?
I MEAN, ARE THEY REALLY STRONG
MODELS THAT WE CAN BE THINKING
ABOUT EXPANDING INTO VARIOUS
SPACES WHERE WE'RE UNDERSTANDING
DEEPER QUESTIONS PARTICULARLY AS
PEOPLE CHANGE RIGHT, FROM THE
MOMENT OF INJURY OR IMPACT AS
TIME GOES ON, THOSE FORCES ON
THEIR HEALTH AND THEIR REHAB
POTENTIAL MAY BE SIGNIFICANTLY
EXEXPANDED UPON GOING BACK IT
WHAT RALPH WAS TALKING ABOUT A
LOT ARE ACUTE BUT WHAT DID
CRONISITY MEAN AND HOW CAN WE BE
ADAPTIVE BUT PRECISE AS PEOPLE
GO ON THROUGH THEIR COURSE OF
THEIR INJURY.
>> GREAT BRACHYTHERAPY.
DO WE HAVE ENOUGH?
>> I THINK WE HAVE A GREAT
START.
AND I I'M SURE THAT WE CAN
TERESA AND RALPH ARK DITIONAL
THOUGHTS AS WE MOVE TOWARD
FORWARD, 1 OF THE OTHER
QUESTIONS WE WANT TO TALK ABOUT
IS YOUR THOUGHTS ABOUT THE
HYBRID FORMAT, IS IT WORKS, HOW
IS IT WORKING, ARE THERE THINGS
WE CAN CHANGE OR IMPROVE?
AND DO WE NEED 2 DAYS, DO WE
WANT TO CHANGE IT TO A DAY?
OR 2 HALF DAYS?
>> HI, I'M SORRY.
>> NO, YOU WERE FIRST.
>> JUST QUICKLY I WOULD SAY THAT
REGARDLESS OF LANDING ON A DAY
AND HALF OR 2 HALF OR STARTING
LATE OR ANYWAY, BUT I WOULD
ADVOCATE FOR THE HYBRID FORMAT
SIMPLY BECAUSE IT ALLOWS PEOPLE
TO PARTICIPATE AND INCLUDES
EVERYBODY, SO THE IDEA THAT
MAYBE I WOULD BE PLANNING TO
COME HERE BUT SOMETHING HAPPENS
AND I YOU KNOW I CAN'T LEAVE THE
HOUSE FOR A WHILE, BUT I CAN
STILL BE HERE IN OTHER PEOPLE
THAT SIMPLY HAVE--NEED TO WORK
FROM A HOME LOCATION, SO I'M A
BIG ADVOCATE AND HYBRID AND
THAT'S HOW I SEE THE WORLD NOW
IS WE NEED TO BE HYBRID BECAUSE
THAT INCLUDES EVERYBODY.
>> I WOULD JUST FOLLOW UP WITH
SAYING THAT WE ARE PRIVILEGED TO
BE IN A HYBRID ENVIRONMENT WITH
THE LEVEL OF SUPPORT THAT WE
HAVE SO THAT IT ACTUALLY WORKS.
THIS IS NOT THE NORM IN A LOT OF
HYBRID SITUATIONS THAT I'VE BEEN
IN.
BOB?
>> YEAH, I AGREE WITH THAT IN
TERMS OF THE FORMAT, I LIKE
HAVING THE IN-PERSON OPTION, 1
DAY VERSUS 1 HALF, 2 DAYS MY
CONCERN IS ACTUALLY THAT IF WE
MAKE IT 1 DAY IT'S GOING TO
BECOME COMPLETELY REMOTE BECAUSE
IT'S NOT--PEOPLE AREN'T GOING TO
FLY IN FOR 1 DAY, PROBABLY NOT
DRIVE EITHER, SO, I THINK IT'S
PRETTY GOOD THE WAY IT IS.
>> I REALLY WANTED TO BE HERE IN
PERSON AS A NEW MEMBER TO GET TO
MEET PEOPLE AND GET TO KNOW
PEOPLE AND I THINK ALTHOUGH LAST
NIGHT WAS A SOCIAL EVENT, IT WAS
VERY HELPFUL TO HAVE A CHANCE TO
MEET AND TALK WITH PEOPLE AND I
THINK THAT WOULD BE HARD TO DO
ON A 1 DAY, BECAUSE EVERYBODY
WOULD LEAVE, RIGHT, AFTER THE
5:00.
>> THAT WAS VERY HELPFUL.
THANK YOU.
>> THERE, THANK YOU AGAIN TO
EVERYONE FOR YOUR THOUGHTFUL AND
ACTIVE PARTICIPATION OVER THESE
LAST 2 DAYS.
AND WISHING EVERYONE SAFE
TRAVELS.
>> AND I HAVE A LIST OF THANK
YOUS I HAVE TO GO GO THROUGH SO
FIRST THIS WAS BARBARA'S FESTER
MEETING AS CHAIR SO I THINK SHE
DID A GREAT JOB.
WE NEED TO THANK ELIZA, BECAUSE
NONE OF YOU WOULD BE HERE IF IT
WASN'T FOR ALL THE LOGISTICS
THAT ELIZA HAS DONE AND WHEN SHE
ASKED FOR RECEIPTS, I EXPECT ALL
OF YOU TO GET BACK TO HER RIGHT
AWAY.
I WANT TO THANK THE IN-ROOM
INFINITY TEAM, DEBBIE AND CHEN
ARD, THERE ARE OTHER IT PEOPLE,
THERE ARE I.T. PEOPLE ONLINE,
THEY ARE AT THE NIH VIDEOCAST SO
WOE HAVE LOTS OF SUPPORT AND AS
BARBARA SAID THEY'VE DONE A
FABULOUS JOB MAKING THIS.
I WANT TO THANK OUR SPEAKERS OUR
GUEST SPEAKERS YESTERDAY, OUR
SPEAKERS TODAY, THANK YOU SO
MUCH.
AND THEN ALL THE BOARD MEMBERS
FOR FILLING OUT YOUR PAPERWORK,
AND FOR REAL LYE FOR YOUR ACTIVE
PARTICIPATION, YOUR ENGAGE AM,
ISSUE THE GREAT QUESTIONS, WE DO
APPRECIATE IT AND THEN OF
COURSE, RALPH, HE HAS--HE MAKES
THIS HAPPEN, SO A BIG HAND TO
HIM.
THANK YOU ALL AND TRAVEL SAFE.
THANK YOU EVERYONE, HOPE TO YOU
SEE IN PERSON IN MAY.