1 00:00:05,360 --> 00:00:15,960 >>I'M AT THE NCCIH, NIH. 2 00:00:15,960 --> 00:00:20,400 ON BEHALF 3 00:00:20,400 --> 00:00:23,720 OF THE ENTIRE NIH-WIDE PLANNING 4 00:00:23,720 --> 00:00:28,000 COMMITTEE FOR THIS WORKSHOP I 5 00:00:28,000 --> 00:00:30,440 WANT TO WELCOME YOU TO DAY 2 OF 6 00:00:30,440 --> 00:00:31,280 UNDERSTANDING AND RESTORING 7 00:00:31,280 --> 00:00:32,640 WHOLE JOINT HEALTH IN PAIN 8 00:00:32,640 --> 00:00:33,360 MANAGEMENT AN NIH HEAL 9 00:00:33,360 --> 00:00:34,360 INITIATIVE WORKSHOP. BEFORE WE 10 00:00:34,360 --> 00:00:36,520 BEGIN I WOULD LIKE TO COVER A 11 00:00:36,520 --> 00:00:39,720 FEW LOGISTICS FOR THIS MEETING. 12 00:00:39,720 --> 00:00:42,360 REMINDER FOR ZOOM ATTENDEES TO 13 00:00:42,360 --> 00:00:43,960 MUTE YOURSELF WHEN NOT SPEAKING 14 00:00:43,960 --> 00:00:45,400 AND RAISE YOUR DIGITAL HAND IF 15 00:00:45,400 --> 00:00:47,040 YOU HAVE COMMENTS AND MAKE SURE 16 00:00:47,040 --> 00:00:49,400 YOUR VIDEO IS ON DURING YOUR 17 00:00:49,400 --> 00:00:50,960 SESSION PARTICULARLY WITH WHEN 18 00:00:50,960 --> 00:00:52,720 SHARING COMMENTS OR THOUGHTS AND 19 00:00:52,720 --> 00:00:56,720 FOR OUR NIH VIDEOCAST VIEWERS A 20 00:00:56,720 --> 00:00:58,760 WARM WELCOME AND REMINDER THAT 21 00:00:58,760 --> 00:01:01,360 YOU MAY SUBMIT A QUESTION AT ANY 22 00:01:01,360 --> 00:01:03,720 TIME USING THE VIDEOCAST 23 00:01:03,720 --> 00:01:05,360 FEEDBACK FORM. THE LINK FOR 24 00:01:05,360 --> 00:01:07,400 THAT FORM WILL BE DIRECTLY BELOW 25 00:01:07,400 --> 00:01:10,400 THE SCREEN WHERE YOU ARE VIEWING 26 00:01:10,400 --> 00:01:12,080 THE SLIDE STREAM. NOW, OUR 27 00:01:12,080 --> 00:01:13,760 QUESTION AND ANSWER PERIODS ARE 28 00:01:13,760 --> 00:01:16,920 NOT HUGE, PARTICULARLY FOR 29 00:01:16,920 --> 00:01:18,400 AUDIENCE AND ZOOM PARTICIPANT 30 00:01:18,400 --> 00:01:18,720 QUESTIONS. 31 00:01:18,720 --> 00:01:21,280 WE WILL TRY TO GET TO AS MANY 32 00:01:21,280 --> 00:01:23,000 QUESTIONS OF YOURS AS WE 33 00:01:23,000 --> 00:01:24,600 POSSIBLY CAN DURING THAT TIME. 34 00:01:24,600 --> 00:01:26,320 BUT, IF WE DON'T GET TO YOUR 35 00:01:26,320 --> 00:01:28,480 QUESTION, DON'T WORRY. WE WILL 36 00:01:28,480 --> 00:01:30,320 ACTUALLY AGGREGATE ALL OF THE 37 00:01:30,320 --> 00:01:32,200 QUESTIONS THAT YOU POSE AND WE 38 00:01:32,200 --> 00:01:33,800 WILL SHARE THEM WITH YOUR 39 00:01:33,800 --> 00:01:35,040 PLANNING TEAM MEMBERS. 40 00:01:35,040 --> 00:01:38,080 FINALLY, THIS MEETING IS BEING 41 00:01:38,080 --> 00:01:39,680 RECORDED. IT WILL BE ARCHIVED 42 00:01:39,680 --> 00:01:42,800 ON THE NIH VIDEOCAST WEBSITE FOR 43 00:01:42,800 --> 00:01:45,440 FUTURE VIEWING IN THE PAST EV 44 00:01:45,440 --> 00:01:50,800 EVENTS SECTION. IF YOU HAVE TO 45 00:01:50,800 --> 00:01:52,920 COME AND GO TODAY WATCHING THE 46 00:01:52,920 --> 00:01:54,800 LIVESTREAM THAT IS FINE. WE ARE 47 00:01:54,800 --> 00:01:57,920 RECORDING FOR LATER VIEWING AND 48 00:01:57,920 --> 00:01:59,960 REMINDERS COVERED, I'M PLEASED 49 00:01:59,960 --> 00:02:06,280 TO INVITE DR. WALTER KORISHETZ 50 00:02:06,280 --> 00:02:08,200 TO WELCOME OUR PARTICIPANTS AND 51 00:02:08,200 --> 00:02:18,800 OFFER OPENING REMARKS FOR DAY 2. 52 00:02:37,160 --> 00:02:40,920 DR. KOROSHETZ, WE ARE GRATEFUL 53 00:02:40,920 --> 00:02:43,080 YOU COULD JOIN TODAY. WE WILL 54 00:02:43,080 --> 00:02:45,080 TURN THINGS OVER FOR YOUR 55 00:02:45,080 --> 00:02:45,560 COMMENTS. 56 00:02:45,560 --> 00:02:46,520 THANK YOU. 57 00:02:46,520 --> 00:02:51,360 >>THANK YOU SO MUCH, CATHERINE. 58 00:02:51,360 --> 00:02:55,280 MY PLEASURE. [INDISCERNIBLE] TO 59 00:02:55,280 --> 00:03:02,520 JOIN AND I GUESS I THINK IT WAS 60 00:03:02,520 --> 00:03:04,760 ANNA MARIE SAID THAT THE DRG AND 61 00:03:04,760 --> 00:03:07,720 [INDISCERNIBLE] IS FAR AWAY BUT 62 00:03:07,720 --> 00:03:10,600 AXONS AND DENDRITES AND NERVE 63 00:03:10,600 --> 00:03:14,400 ENDINGS ARE JOINTS AND REALLY 64 00:03:14,400 --> 00:03:16,680 APPRECIATE IT. WE WILL TALK A 65 00:03:16,680 --> 00:03:19,160 LITTLE TODAY ABOUT 66 00:03:19,160 --> 00:03:21,680 NEUROSCIENTISTS AND I WANTED TO 67 00:03:21,680 --> 00:03:23,040 JUST FILL OUT A LITTLE ABOUT 68 00:03:23,040 --> 00:03:27,960 WHAT HEAL IS DOING IN THE PAIN 69 00:03:27,960 --> 00:03:28,320 SPACE. 70 00:03:28,320 --> 00:03:34,960 AND SO JUST TO SAY THAT HEAL IS 71 00:03:34,960 --> 00:03:40,920 TRYING TO ATTACK A MAJOR PROBLEM 72 00:03:40,920 --> 00:03:43,320 WHICH IS CHRONIC PAIN AND MAIN 73 00:03:43,320 --> 00:03:45,360 THING TO KNOW IS CHRONIC PAIN IS 74 00:03:45,360 --> 00:03:46,680 REALLY LIMITING WHAT PEOPLE CAN 75 00:03:46,680 --> 00:03:49,080 DO AND PERCENTAGE OF PEOPLE 76 00:03:49,080 --> 00:03:53,280 WORSE IN RURAL AREAS AND URBAN 77 00:03:53,280 --> 00:03:56,280 AREAS AND THERE IS A LOT OF 78 00:03:56,280 --> 00:03:58,160 COMORBIDITIES IN PEOPLE WITH 79 00:03:58,160 --> 00:04:00,240 SEVERE CHRONIC PAIN THAT IS A 80 00:04:00,240 --> 00:04:04,120 REALLY COMPLICATED PROBLEM TO 81 00:04:04,120 --> 00:04:06,320 SOLVE. THAT IS WHAT HEAL IS ALL 82 00:04:06,320 --> 00:04:08,360 ABOUT. IT IS -- YOU KNOW, IT 83 00:04:08,360 --> 00:04:10,720 WAS INITIATED AT FIRST BECAUSE 84 00:04:10,720 --> 00:04:15,960 IT WAS TRYING TO TREAT PAIN THAT 85 00:04:15,960 --> 00:04:19,240 PHYSICIANS GOT REALLY OVERBOARD 86 00:04:19,240 --> 00:04:22,800 IN TERMS OF [INDISCERNIBLE] AND 87 00:04:22,800 --> 00:04:24,760 OVERDOSE CRISIS, WHICH IS NOW, 88 00:04:24,760 --> 00:04:28,480 YOU KNOW, LESSENED IN TERMS OF 89 00:04:28,480 --> 00:04:29,960 PRESCRIPTION DRUGS AND 90 00:04:29,960 --> 00:04:32,960 FORTUNATELY STIMULATED AN ENTIRE 91 00:04:32,960 --> 00:04:37,360 INDUSTRY OF ILLEGAL DRUGS AND 92 00:04:37,360 --> 00:04:39,760 FENTANYL AND DEATHS KEEPS GOING 93 00:04:39,760 --> 00:04:42,760 UP AND HEAL STANDS FOR ADDING 94 00:04:42,760 --> 00:04:44,000 ADDICTION LONG TERM AND ONLY WAY 95 00:04:44,000 --> 00:04:47,720 TO DO THAT IS REALLY TO DEVELOP 96 00:04:47,720 --> 00:04:50,920 DRUGS AND BETTER WAYS FOR PAIN 97 00:04:50,920 --> 00:04:51,960 LIMITED RISK OF ADDICTION AND 98 00:04:51,960 --> 00:04:56,640 WHAT HEAL IS ALL ABOUT. 99 00:04:56,640 --> 00:04:59,000 NOW, MANY KNOW AS WELL AS I DO 100 00:04:59,000 --> 00:05:01,040 THAT MAIN MANAGEMENT IS 101 00:05:01,040 --> 00:05:02,960 CHALLENGING FOR LOTS OF 102 00:05:02,960 --> 00:05:04,400 DIFFERENT ASPECTS. IT IS 103 00:05:04,400 --> 00:05:05,480 COMPLEX FOR SURE. 104 00:05:05,480 --> 00:05:09,560 CLEARLY, THE WORK THAT YOU TALK 105 00:05:09,560 --> 00:05:13,200 ABOUT YESTERDAY INDICATES HOW 106 00:05:13,200 --> 00:05:15,560 COMPLEX IT IS AT THE JOINT LEVEL 107 00:05:15,560 --> 00:05:19,800 AND COMPLEX IT IS IN DRG AND 108 00:05:19,800 --> 00:05:21,040 SPINAL CORD AND BRAIN LEVEL AS 109 00:05:21,040 --> 00:05:23,040 WELL. I DON'T THINK WE HAVE THE 110 00:05:23,040 --> 00:05:27,000 WORKFORCE WE NEED TO ATTACK THIS 111 00:05:27,000 --> 00:05:27,280 PROBLEM. 112 00:05:27,280 --> 00:05:29,360 TRAINING, YOU KNOW, BECAUSE IT 113 00:05:29,360 --> 00:05:32,080 IS A VERY CROSS-DISCIPLINARY 114 00:05:32,080 --> 00:05:32,560 PROBLEM. 115 00:05:32,560 --> 00:05:34,920 IT IS REALLY CHALLENGED. I CAN 116 00:05:34,920 --> 00:05:37,360 TELL YOU RIGHT NOW IN TRYING TO 117 00:05:37,360 --> 00:05:40,200 DO EARLY PHASE TRIAL AND 118 00:05:40,200 --> 00:05:43,320 OSTEOPATH AND OSTEOARTHRITIS AND 119 00:05:43,320 --> 00:05:45,040 HAVING TREMENDOUS 120 00:05:45,040 --> 00:05:47,960 [INDISCERNIBLE] IN ROLLING 121 00:05:47,960 --> 00:05:51,200 PATIENTS AND NETWORK IN PHASE 2 122 00:05:51,200 --> 00:05:54,000 TRIAL AND GOING AT THE RATE AND 123 00:05:54,000 --> 00:05:55,200 WORKFORCE TO DO THIS RIGHT NOW. 124 00:05:55,200 --> 00:05:57,760 THERE IS A LOT OF ISSUES WITH 125 00:05:57,760 --> 00:05:59,880 ACCESS TO PAIN THERAPY FOR A 126 00:05:59,880 --> 00:06:01,920 VARIETY OF DIFFERENT REASONS AND 127 00:06:01,920 --> 00:06:04,680 SOME IS A LACK OF REALLY GOOD 128 00:06:04,680 --> 00:06:05,920 PAIN [INDISCERNIBLE] AROUND THE 129 00:06:05,920 --> 00:06:09,120 COUNTRY. THERE IS ALSO BIAS AND 130 00:06:09,120 --> 00:06:10,720 STIGMA PEOPLE WITH PAIN AND 131 00:06:10,720 --> 00:06:12,240 SUFFERING BECAUSE THEY CAN'T DO 132 00:06:12,240 --> 00:06:15,480 WHAT THEY WANT TO DO BUT THEY 133 00:06:15,480 --> 00:06:17,800 DON'T LOOK ANY WORSE THAN 134 00:06:17,800 --> 00:06:20,920 ANYBODY ELSE AND THEY COMPLAIN 135 00:06:20,920 --> 00:06:23,320 OF THEIR PAIN AND KIND OF SHRUG 136 00:06:23,320 --> 00:06:26,400 THEM OFF. THERE IS A LOT OF 137 00:06:26,400 --> 00:06:28,240 BIAS THERE AND REIMBURSEMENT TO 138 00:06:28,240 --> 00:06:30,440 TAKE CARE OF CHRONIC PAIN IS NOT 139 00:06:30,440 --> 00:06:33,720 PROCEDURES BUT IS REALLY TOUGH 140 00:06:33,720 --> 00:06:37,880 TO GET TO COVER YOUR COSTS. 141 00:06:37,880 --> 00:06:39,880 SO, YEAH. WHAT WE ARE TRYING TO 142 00:06:39,880 --> 00:06:42,960 DO IN HEAL IS ACCELERATE 143 00:06:42,960 --> 00:06:45,360 DISCOVERY AND DEVELOPMENT OF 144 00:06:45,360 --> 00:06:46,400 NONADDICTIVE PAIN TREATMENTS AND 145 00:06:46,400 --> 00:06:48,520 REASON THAT IT IS ACTUALLY 146 00:06:48,520 --> 00:06:50,360 STARTING IN THE FIRST PLACE AND 147 00:06:50,360 --> 00:06:52,720 TRUTH OF THE MATTER IS THAT, YOU 148 00:06:52,720 --> 00:06:56,400 KNOW, WITHOUT NIH IN THIS SPACE, 149 00:06:56,400 --> 00:07:00,160 VERY LITTLE WILL HAPPEN IN PAIN 150 00:07:00,160 --> 00:07:03,040 THERAPEUTICS THAT IS PALTRY, 151 00:07:03,040 --> 00:07:06,160 REALLY. AND IT IS -- YOU KNOW, 152 00:07:06,160 --> 00:07:08,080 IT IS ACTUALLY MUCH WORSE THAN 153 00:07:08,080 --> 00:07:09,880 IT WAS A COUPLE YEARS AGO 154 00:07:09,880 --> 00:07:12,240 BECAUSE OF THE BIG FAILURES OF 155 00:07:12,240 --> 00:07:14,080 LARGE PAIN TRIALS AND, YOU KNOW, 156 00:07:14,080 --> 00:07:21,160 EVEN GOING INTO, YOU KNOW, THE 157 00:07:21,160 --> 00:07:21,600 BIOCS ISSUE WHERE 158 00:07:21,600 --> 00:07:24,800 [INDISCERNIBLE] AND DRUG OUT. 159 00:07:24,800 --> 00:07:28,680 SO, [AUDIO SKIPPING]. 160 00:07:28,680 --> 00:07:32,720 >>DR. KOROSHETZ, I HATE TO 161 00:07:32,720 --> 00:07:35,040 BOTHER YOU. YOU SEEM TO BE 162 00:07:35,040 --> 00:07:36,200 BREAKING UP ON YOUR AUDIO A 163 00:07:36,200 --> 00:07:37,640 LITTLE BIT. 164 00:07:37,640 --> 00:07:39,440 DO YOU WANT TO TRY GETTING A 165 00:07:39,440 --> 00:07:41,600 LITTLE CLOSER TO THE MICROPHONE? 166 00:07:41,600 --> 00:07:45,480 MIGHT THAT BE THE ISSUE? 167 00:07:45,480 --> 00:07:47,320 >>OKAY. 168 00:07:47,320 --> 00:07:52,240 >>ALSO COULD BE VPN, DR. 169 00:07:52,240 --> 00:07:55,480 KOROSHETZ IF YOU ARE ON VPN? 170 00:07:55,480 --> 00:07:58,480 >>I'M HOOKED UP TO A NETWORK. 171 00:07:58,480 --> 00:08:00,920 >>OH, DEAR. LET'S KEEP GOING 172 00:08:00,920 --> 00:08:04,960 DR. KOROSHETZ. MAYBE, YOU KNOW, 173 00:08:04,960 --> 00:08:06,800 JUST BE AWARE IT IS BREAKING UP 174 00:08:06,800 --> 00:08:11,160 A LITTLE BIT AND WE WILL SEE IF 175 00:08:11,160 --> 00:08:12,080 IT IMPROVES. 176 00:08:12,080 --> 00:08:14,720 >>OKAY. MAYBE PUT YOUR FINGER 177 00:08:14,720 --> 00:08:17,200 THUMB UP OR DOWN IF IT IS BAD. 178 00:08:17,200 --> 00:08:20,040 >>IT IS GETTING A LITTLE 179 00:08:20,040 --> 00:08:21,360 BETTER. LET'S KEEP GOING. 180 00:08:21,360 --> 00:08:24,400 >>OKAY. ALL RIGHT. SO 181 00:08:24,400 --> 00:08:26,120 DEVELOPING NONADDICTIVE PAIN 182 00:08:26,120 --> 00:08:28,680 TREATMENTS IS ONE OF THE BIG 183 00:08:28,680 --> 00:08:31,440 PRIORITIES OF HEAL. 184 00:08:31,440 --> 00:08:35,440 THEN ADVANCING THROUGH CLINICAL 185 00:08:35,440 --> 00:08:38,080 [INDISCERNIBLE] AND OUTPATIENTS 186 00:08:38,080 --> 00:08:41,400 WORKING WITH THE INDUSTRY TO 187 00:08:41,400 --> 00:08:42,480 COMMERCIALIZE DISCOVERIES THAT 188 00:08:42,480 --> 00:08:44,920 HAVE BEEN MADE IN THE LABS AND 189 00:08:44,920 --> 00:08:51,320 BIG PART OF HEAL IS INFORMING 190 00:08:51,320 --> 00:08:53,920 [AUDIO BREAKING UP]. 191 00:08:53,920 --> 00:08:56,560 THIS IS USING THERAPIES THAT ARE 192 00:08:56,560 --> 00:09:00,080 AVAILABLE BUT USING THEM IN A 193 00:09:00,080 --> 00:09:02,400 MORE EFFECTIVE FASHION AND 194 00:09:02,400 --> 00:09:08,040 PAYING ATTENTION RISK OF 195 00:09:08,040 --> 00:09:11,200 ADDICTION AND IN TERMS OF 196 00:09:11,200 --> 00:09:12,480 UNDERSTANDING, I'M SURE WE ARE 197 00:09:12,480 --> 00:09:15,960 ONLY A SHORT PERCENTAGE OF THE 198 00:09:15,960 --> 00:09:21,160 WAY OF UNDERSTAND IING TARGETS D 199 00:09:21,160 --> 00:09:25,520 WHICH TARGETS TO PURSUE AND KNOW 200 00:09:25,520 --> 00:09:30,480 IN HUCHL ANS IF THEY WILL HAVE A 201 00:09:30,480 --> 00:09:34,760 ROBUST EFFECT TO A CLINICAL 202 00:09:34,760 --> 00:09:37,960 TRIAL AND NOBEL PRIZE IN 2021 203 00:09:37,960 --> 00:09:41,280 WAS IN MOLECULAR DISCOVERIES IN 204 00:09:41,280 --> 00:09:43,320 CHILD AND PAIN AND INTERESTING 205 00:09:43,320 --> 00:09:45,800 DISCOVERIES AND RELATED TO 206 00:09:45,800 --> 00:09:49,080 SENSITIVITY AND [INDISCERNIBLE] 207 00:09:49,080 --> 00:09:57,000 SENSITIVITY TO PAIN. 208 00:09:57,000 --> 00:09:58,920 SYSTEM IS COMPLEX. PAIN SYSTEM 209 00:09:58,920 --> 00:10:02,280 WAS BUILT. IT IS A REALLY OLD 210 00:10:02,280 --> 00:10:03,920 SYSTEM. BASICALLY EVERY ANIMAL 211 00:10:03,920 --> 00:10:06,200 HAS A PAIN SYSTEM THAT IS 212 00:10:06,200 --> 00:10:08,840 BASICALLY TO PROTECT THE ANIMAL 213 00:10:08,840 --> 00:10:10,720 FROM INJURY AND I'M SURE THAT 214 00:10:10,720 --> 00:10:15,080 GIVEN THE MECHANICS FOR A JOINT 215 00:10:15,080 --> 00:10:25,640 AND THE -- THE REAL DOWNSIDE OF 216 00:10:26,480 --> 00:10:28,360 HAVING JOINT DEFORMITY FROM 217 00:10:28,360 --> 00:10:29,720 HUNTING OR GATHERING. 218 00:10:29,720 --> 00:10:31,640 YOU KNOW, SYSTEMS THAT HAVE BEEN 219 00:10:31,640 --> 00:10:34,040 PUT TOGETHER TO REALLY PROTECT 220 00:10:34,040 --> 00:10:36,720 YOUR JOINTS. 221 00:10:36,720 --> 00:10:40,600 SO, PAIN, THE PAIN SYSTEM IS 222 00:10:40,600 --> 00:10:42,200 CRITICAL FOR THE LIFE OF THE 223 00:10:42,200 --> 00:10:42,440 JOINT. 224 00:10:42,440 --> 00:10:46,320 THE OTHER THING TO KNOW IS THAT 225 00:10:46,320 --> 00:10:54,200 PAIN HAS A SIMPLISTIC VIEW AND 226 00:10:54,200 --> 00:10:55,480 COMPONENT AND STIMULUS YOU FEEL 227 00:10:55,480 --> 00:10:57,800 PAIN AND GO AWAY AND THAT IS NOT 228 00:10:57,800 --> 00:11:01,840 ALL IT IS TRYING TO DO. 229 00:11:01,840 --> 00:11:04,960 IT HAS AN AMAZING MEMORY SYSTEM 230 00:11:04,960 --> 00:11:07,560 SO WHEN YOU FEEL PAIN YOU WON'T 231 00:11:07,560 --> 00:11:10,320 GO BACK TO SAME SITUATION AND 232 00:11:10,320 --> 00:11:14,880 YOU ARE JOINED IN ANOTHER INJURY 233 00:11:14,880 --> 00:11:16,200 POTENTIAL POSITION BECAUSE PAIN 234 00:11:16,200 --> 00:11:19,280 STOCHS YOU FROM DOING THAT PAIN 235 00:11:19,280 --> 00:11:20,640 AND PREVENTS YOU FROM DOING 236 00:11:20,640 --> 00:11:23,480 THAT. THAT MEMORY SYSTEM IS 237 00:11:23,480 --> 00:11:27,920 REALLY WHAT IS PRODUCED BY THE 238 00:11:27,920 --> 00:11:31,320 PLASTICITY IN THE NERVOUS SYSTEM 239 00:11:31,320 --> 00:11:35,680 TO CREATE THAT SENSE OF 240 00:11:35,680 --> 00:11:36,680 BASICALLY SUFFERING THAT WILL 241 00:11:36,680 --> 00:11:42,160 DRIVE YOU AWAY FROM THAT 242 00:11:42,160 --> 00:11:47,560 STIMULUS AGAIN. 243 00:11:47,560 --> 00:11:50,200 AND UNFORTUNATELY LONG TERM CAN 244 00:11:50,200 --> 00:11:54,400 BECOME CHRONIC. IT IS NOT 245 00:11:54,400 --> 00:11:59,600 ENTIRELY CLEAR WHERE FIRES ARE 246 00:11:59,600 --> 00:12:03,280 COULD BE IN PLASTICITY THAT IS 247 00:12:03,280 --> 00:12:05,640 DEVELOPED IN MEMORY PAIN BUT 248 00:12:05,640 --> 00:12:07,680 CERTAINLY PEOPLE HAVE CHRONIC 249 00:12:07,680 --> 00:12:12,480 PAIN DUE TO KNEE AND OSTEOCAN 250 00:12:12,480 --> 00:12:15,760 ARTHRITIS AND 80 PERCENT OF THEM 251 00:12:15,760 --> 00:12:19,480 HAVE PAIN IN [INDISCERNIBLE] AND 252 00:12:19,480 --> 00:12:21,440 EFFECTING THE IN SYSTEM 253 00:12:21,440 --> 00:12:23,360 SOUTHBOUND FOR 80% OF THE PEOPLE 254 00:12:23,360 --> 00:12:24,520 AND FOR EVERYBODY AND THAT IS 255 00:12:24,520 --> 00:12:26,840 THE BIG QUESTION IS WHETHER 256 00:12:26,840 --> 00:12:28,160 PEOPLE DEVELOP CHRONIC PAIN EVEN 257 00:12:28,160 --> 00:12:31,760 AFTER YOU TAKE CARE OF THE 258 00:12:31,760 --> 00:12:34,840 PERIPHERAL ISSUE, WHETHER THAT 259 00:12:34,840 --> 00:12:39,440 IS SOMETHING THAT IS STILL 260 00:12:39,440 --> 00:12:41,120 REGARDING AND DUE TO SOME 261 00:12:41,120 --> 00:12:43,480 DISFUNCTION AT THE PERIPHERY OR 262 00:12:43,480 --> 00:12:46,720 WHETHER THERE IS A CENTRAL 263 00:12:46,720 --> 00:12:50,120 FUNCTION THAT HAS HAPPENED. 264 00:12:50,120 --> 00:12:52,120 AT THE NERVES BASICALLY -- 265 00:12:52,120 --> 00:12:54,840 >>WE ARE ACTUALLY REALLY LOSING 266 00:12:54,840 --> 00:12:59,320 YOU DR. KOROSHETZ. WANT TO TRY 267 00:12:59,320 --> 00:13:01,320 SOMETHING FOR ME AND TURN OFF 268 00:13:01,320 --> 00:13:03,160 YOUR VIDEO QUICKLY TO SEE IF 269 00:13:03,160 --> 00:13:06,200 THAT TAKES CARE OF THE BANDWIDTH 270 00:13:06,200 --> 00:13:09,120 ISSUE WE ARE EXPERIENCING? 271 00:13:09,120 --> 00:13:09,440 >>OKAY. 272 00:13:09,440 --> 00:13:11,880 >>YOU CAN KEEP SHARING YOUR 273 00:13:11,880 --> 00:13:12,520 SLIDES. 274 00:13:12,520 --> 00:13:13,440 THAT IS FINE. 275 00:13:13,440 --> 00:13:15,080 MAYBE STOP THE VIDEO FOR A 276 00:13:15,080 --> 00:13:16,520 SECOND WHILE YOU ARE SPEAKING 277 00:13:16,520 --> 00:13:18,280 AND SEE IF IT HELPS TO BRING 278 00:13:18,280 --> 00:13:22,320 YOUR CONCLUSION TO THE LAST FEW 279 00:13:22,320 --> 00:13:28,160 SLIDES HERE. 280 00:13:28,160 --> 00:13:32,120 HOW ABOUT I GO AHEAD AND WILL 281 00:13:32,120 --> 00:13:33,760 STOP YOUR VIDEO TEMPORARILY 282 00:13:33,760 --> 00:13:38,280 SEEING IF IT HELPS. YOU CAN GO 283 00:13:38,280 --> 00:13:41,160 AHEAD AND SHARE THE FULL SCREEN 284 00:13:41,160 --> 00:13:44,960 ON YOUR SLIDES AGAIN AND KEEP 285 00:13:44,960 --> 00:13:47,960 GOI 286 00:13:47,960 --> 00:13:48,200 GOING. 287 00:13:48,200 --> 00:13:49,080 >>ONE SECOND. 288 00:13:49,080 --> 00:13:50,960 >>IF IT DOESN'T IMPROVE THE 289 00:13:50,960 --> 00:13:52,720 AUDIO YOU CAN JUST GO TO. 290 00:13:52,720 --> 00:13:53,560 >>HOW ABOUT NOW? 291 00:13:53,560 --> 00:13:56,480 >>WE CAN HEAR YOU MUCH BETTER 292 00:13:56,480 --> 00:14:00,680 NOW DR. KOROSHETZ, THANK YOU. 293 00:14:00,680 --> 00:14:03,440 >>OKAY. 294 00:14:03,440 --> 00:14:04,560 >>SLOOID SHARE PRESENTATION 295 00:14:04,560 --> 00:14:06,680 MODE DOWN AT THE -- THAT IS 296 00:14:06,680 --> 00:14:06,960 PERFECT. 297 00:14:06,960 --> 00:14:07,400 >>OKAY. 298 00:14:07,400 --> 00:14:10,120 >>OKAY. GREAT. KEEP GOING 299 00:14:10,120 --> 00:14:14,840 THERE. THANK YOU, DR. 300 00:14:14,840 --> 00:14:15,160 KOROSHETZ. 301 00:14:15,160 --> 00:14:18,480 >>OKAY. SORRY ABOUT THAT. SO, 302 00:14:18,480 --> 00:14:19,920 THE QUESTION I THINK FOR THE 303 00:14:19,920 --> 00:14:23,120 GROUP IS TO WORK IN THIS SPACE 304 00:14:23,120 --> 00:14:25,080 TO TRY TO UNDERSTAND ALL OF THE 305 00:14:25,080 --> 00:14:27,800 DIFFERENT MEDIATORS OF 306 00:14:27,800 --> 00:14:29,080 ACTIVATION OF THESE PAIN FIBERS 307 00:14:29,080 --> 00:14:34,920 IN THE JOINT AND IN THE BONE AND 308 00:14:34,920 --> 00:14:37,960 TISSUES AND THAT IS REALLY 309 00:14:37,960 --> 00:14:41,200 IMPORTANT BECAUSE INTERVENING AT 310 00:14:41,200 --> 00:14:48,320 THE PERIPHERY IS PROBABLY MORE 311 00:14:48,320 --> 00:14:50,920 LIKELY TO BE SUCCESSFUL GOING 312 00:14:50,920 --> 00:14:55,360 MORE CENTURY IN TARGET EFFECTS 313 00:14:55,360 --> 00:14:57,920 EFFECTING OTHER NEUROSYSTEMS AND 314 00:14:57,920 --> 00:15:00,760 EFFORTS YOU ARE WORKING ON WILL 315 00:15:00,760 --> 00:15:03,160 REALLY PAY OFF IF WE TRY TO 316 00:15:03,160 --> 00:15:04,880 UNDERSTAND HOW TO INTERCEPT PAIN 317 00:15:04,880 --> 00:15:09,160 SIGNALS COMING FROM THE TISSUES 318 00:15:09,160 --> 00:15:12,760 TO ACTIVATE THE NOSE RECEPTORS 319 00:15:12,760 --> 00:15:14,560 AND THINK THAT THE IMPORTANCE OF 320 00:15:14,560 --> 00:15:17,360 THE JOINT AS THE ORGAN OF 321 00:15:17,360 --> 00:15:21,400 INTEREST IS CRITICAL AND AS WAS 322 00:15:21,400 --> 00:15:25,360 MENTIONED YESTERDAY, ES CAPPADE 323 00:15:25,360 --> 00:15:27,040 INTO ANTI-NERVE GROWTH FACTOR 324 00:15:27,040 --> 00:15:29,360 FOR PAIN WAS A REALLY GOOD 325 00:15:29,360 --> 00:15:31,480 LESSON WHERE WE PROBABLY GOT 326 00:15:31,480 --> 00:15:36,920 BETTER PAIN CONTROL BUT AT THE 327 00:15:36,920 --> 00:15:39,880 RISK OF WORSE JOINT DISEASE. 328 00:15:39,880 --> 00:15:43,960 SO CENTRALLY THERE IS LOTS OF 329 00:15:43,960 --> 00:15:47,160 THINGS GOING ON IN THE SPINAL 330 00:15:47,160 --> 00:15:48,720 CORD AND BRAIN AND EXAMPLE THAT 331 00:15:48,720 --> 00:15:50,160 IS EASIEST TO UNDERSTAND WHICH 332 00:15:50,160 --> 00:15:54,320 IS PROBABLY DRG OR SPINAL CORD 333 00:15:54,320 --> 00:15:56,840 MEDIATED IS WHEN YOU HAVE A 334 00:15:56,840 --> 00:15:58,280 PAINFUL STIMULUS AND ONE ZONE. 335 00:15:58,280 --> 00:16:03,920 YOU KNOW, WHAT HAPPENS IS AREAS 336 00:16:03,920 --> 00:16:05,840 AROUND IT BECOME HYPERSENSITIVE 337 00:16:05,840 --> 00:16:09,520 AS WELL. STIMULI THAT DON'T 338 00:16:09,520 --> 00:16:11,320 USUALLY TRIGGER PAIN NOW TRIGGER 339 00:16:11,320 --> 00:16:11,680 PAIN. 340 00:16:11,680 --> 00:16:14,160 THAT IS A SIGN OF THIS 341 00:16:14,160 --> 00:16:15,560 PLASTICITY THAT WE SEE ON THE 342 00:16:15,560 --> 00:16:17,200 SKIN ALL THE TIME AND I'M SURE 343 00:16:17,200 --> 00:16:21,200 IT GOES ON IN THE JOINT AS WELL 344 00:16:21,200 --> 00:16:21,880 AND CERTAINLY DON'T UNDERSTAND 345 00:16:21,880 --> 00:16:23,600 WHAT THAT PROCESS LOOKS LIKE IN 346 00:16:23,600 --> 00:16:25,480 TERMS OF PARALLEL TO WHAT 347 00:16:25,480 --> 00:16:26,880 HAPPENS IN THE SKIN. THAT WOULD 348 00:16:26,880 --> 00:16:30,600 BE REALLY INTERESTING TO TRY TO 349 00:16:30,600 --> 00:16:37,000 GET AT. 350 00:16:37,000 --> 00:16:38,280 I GUESS TO ALSO MENTION THAT 351 00:16:38,280 --> 00:16:40,480 THERE IS A LOT OF WORK GOING ON 352 00:16:40,480 --> 00:16:43,520 IN THE BRAIN CIRCUITS AND SPINAL 353 00:16:43,520 --> 00:16:45,360 CORD CIRCUITS THAT HAS TO DO 354 00:16:45,360 --> 00:16:46,520 WITH ADVANCES IN TECHNOLOGY THAT 355 00:16:46,520 --> 00:16:49,240 ARE COMING OUT OF THE BRAIN 356 00:16:49,240 --> 00:16:51,760 INITIATIVE THAT ALLOW FOR VERY, 357 00:16:51,760 --> 00:16:54,360 KIND OF, PRECISE TARGETING OF 358 00:16:54,360 --> 00:16:55,960 SPECIFIC NEURAL GROUPS. 359 00:16:55,960 --> 00:16:57,880 SO, YOU CAN -- YOU KNOW, THE 360 00:16:57,880 --> 00:17:03,080 BEST EXAMPLES ARE AREAS IN THE 361 00:17:03,080 --> 00:17:04,600 AMYG DOULA WHERE YOU TURN CELLS 362 00:17:04,600 --> 00:17:06,240 OFF AND ANIMALS WITHDRAW FROM 363 00:17:06,240 --> 00:17:08,200 PAIN AND HAVE NO SUFFERING 364 00:17:08,200 --> 00:17:09,080 ASSOCIATED WITH IT. 365 00:17:09,080 --> 00:17:11,040 THERE IS WORK GOING ON IN THAT 366 00:17:11,040 --> 00:17:13,040 SPACE THAT IS FAR FROM THE JOINT 367 00:17:13,040 --> 00:17:14,400 BUT IMPORTANT TO UNDERSTAND IN 368 00:17:14,400 --> 00:17:17,360 TERMS OF THE CONTEXT OF WHAT 369 00:17:17,360 --> 00:17:20,880 YOUR JOINT IS ALL ABOUT CH. 370 00:17:20,880 --> 00:17:24,640 A BIG PROBLEM DEVELOPING PAIN 371 00:17:24,640 --> 00:17:28,080 THERAPEUTICS IS LACK OF 372 00:17:28,080 --> 00:17:31,120 BIOMARKERS AND RELIANCE ON A 1 373 00:17:31,120 --> 00:17:34,920 TO 10 SUBJECTIVE PAIN SCALE. 374 00:17:34,920 --> 00:17:36,320 SO, ANYTHING THAT YOU ARE 375 00:17:36,320 --> 00:17:38,480 WORKING ON THAT WOULD LOOK LIKE 376 00:17:38,480 --> 00:17:42,240 A POTENTIAL MARKER OF TARGET 377 00:17:42,240 --> 00:17:44,320 ENGAGEMENT IN A THERAPEUTIC 378 00:17:44,320 --> 00:17:45,880 TRIAL WOULD BE IMPORTANT TO 379 00:17:45,880 --> 00:17:50,320 EXPLORE AND HAVE IN HEAL 380 00:17:50,320 --> 00:17:52,680 BIOMARKER PROGRAMS TO VALIDATE 381 00:17:52,680 --> 00:17:54,680 BIOMARKERS ANALYTICALLY AND 382 00:17:54,680 --> 00:17:56,840 CLINICALLY BECAUSE IT WOULD BE A 383 00:17:56,840 --> 00:17:59,360 TREMENDOUS HELP IN MOVING PAIN 384 00:17:59,360 --> 00:17:59,920 THERAPEUTIC FORWARD. 385 00:17:59,920 --> 00:18:02,920 AS I SAID, THERE IS LACK OF 386 00:18:02,920 --> 00:18:04,200 TARGETS AND QUESTION IS HOW DO 387 00:18:04,200 --> 00:18:05,920 YOU KNOW IF THEY ARE DOING WHAT 388 00:18:05,920 --> 00:18:08,320 YOU THINK THEY ARE DOING GOING 389 00:18:08,320 --> 00:18:10,560 INTO HUMANS AND THERE WE REALLY 390 00:18:10,560 --> 00:18:11,840 NEED BIOMARKERS. 391 00:18:11,840 --> 00:18:16,960 IN THE TRIAL WE ARE DOING WITH 392 00:18:16,960 --> 00:18:18,160 OSTEOARTHRITIS PLAN WAS TO GET 393 00:18:18,160 --> 00:18:19,800 FLUID OUT OF THE JOINT AND LOOK 394 00:18:19,800 --> 00:18:23,320 AT WHETHER THE DRUG COULD REDUCE 395 00:18:23,320 --> 00:18:25,440 INFLAMMATION WITHIN THE SYNOVIAL 396 00:18:25,440 --> 00:18:27,560 FLUID AND PROBLEM IS LOTS OF 397 00:18:27,560 --> 00:18:31,560 PLACES DON'T FEEL COMFORTABLE 398 00:18:31,560 --> 00:18:33,560 STICKING NEEDLES IN JOINTS 399 00:18:33,560 --> 00:18:35,000 ANYMORE AND THAT UNFORTUNATELY 400 00:18:35,000 --> 00:18:36,840 IS NOT WORKING OUT AS WE WISH 401 00:18:36,840 --> 00:18:38,720 AND SOMETHING THAT ALLOWS YOU TO 402 00:18:38,720 --> 00:18:41,080 KNOW THAT YOUR DRUG IS DOING 403 00:18:41,080 --> 00:18:43,280 WHAT YOU HOPE IT IS DOING AT THE 404 00:18:43,280 --> 00:18:45,200 JOINT LEVEL WOULD BE INCREDIBLY 405 00:18:45,200 --> 00:18:47,240 IMPORTANT TO SOME KIND OF 406 00:18:47,240 --> 00:18:48,720 MEASUREMENT THAT MAY BE TEACHING 407 00:18:48,720 --> 00:18:50,280 PEOPLE HOW TO DO JOINT 408 00:18:50,280 --> 00:18:52,760 ASPIRATIONS THAT USED TO BE 409 00:18:52,760 --> 00:18:54,960 PRETTY COMMON IN THE OLD DAYS. 410 00:18:54,960 --> 00:18:57,360 WE HAVE THERAPEUTIC PROGRAMS AS 411 00:18:57,360 --> 00:18:58,880 WELL THAT PEOPLE CAN COME IN FOR 412 00:18:58,880 --> 00:19:00,560 IT AND HAVE SOMETHING THAT LOOKS 413 00:19:00,560 --> 00:19:04,480 LIKE IT WILL BE A TREATMENT OR 414 00:19:04,480 --> 00:19:05,760 JOINT PAIN. 415 00:19:05,760 --> 00:19:07,560 THEY GO THROUGH MULTIPLE 416 00:19:07,560 --> 00:19:08,600 DIFFERENT LEVELS AND FINAL GOAL 417 00:19:08,600 --> 00:19:12,440 IS GETTING TO AN IND AND EVEN 418 00:19:12,440 --> 00:19:15,960 INTO A PHASE 1 TRIAL. 419 00:19:15,960 --> 00:19:18,520 SO HEAL SUPPORTS THIS WHAT WE 420 00:19:18,520 --> 00:19:21,360 CALL DERISKING OF DISCOVERY AND 421 00:19:21,360 --> 00:19:24,160 HOPING INDUSTRY WILL PICK UP 422 00:19:24,160 --> 00:19:26,880 PROGRAMS AS THEY MOVE ALONG INTO 423 00:19:26,880 --> 00:19:29,520 IND PHASE AND BIOMARKERS AS I 424 00:19:29,520 --> 00:19:30,920 MENTIONED AND CLINICAL TRIALS WE 425 00:19:30,920 --> 00:19:32,480 HAVE IN HEAL AND NUMBER OF 426 00:19:32,480 --> 00:19:33,880 CLINICAL TRIALS GOING ON AND 427 00:19:33,880 --> 00:19:37,120 SOME OF THESE ARE IN THE PRISM 428 00:19:37,120 --> 00:19:41,040 SPACE WHERE TESTING PRIMARILY 429 00:19:41,040 --> 00:19:42,200 NON-PHARMACOLOGICAL THERAPIES 430 00:19:42,200 --> 00:19:44,160 AND WE HAVE ALSO THE 431 00:19:44,160 --> 00:19:45,360 EFFECTIVENESS RESEARCH NETWORK 432 00:19:45,360 --> 00:19:50,680 THAT IS TESTING A COMBINATION OF 433 00:19:50,680 --> 00:19:53,240 PHARMACOLOGICAL AND NONFARM 434 00:19:53,240 --> 00:19:55,080 CALOGICAL THERAPIES IN PAGE 435 00:19:55,080 --> 00:19:57,200 CONDITIONS AND ACUTE PAIN 436 00:19:57,200 --> 00:19:58,680 TRANSITION PROGRAM THAT IS GOING 437 00:19:58,680 --> 00:20:01,480 ON IN THE COMMON FUND LOOKING AT 438 00:20:01,480 --> 00:20:03,680 SAY, IMPORTANTLY, THE RISKS 439 00:20:03,680 --> 00:20:06,440 PROFILE OF PEOPLE THAT GO ON TO 440 00:20:06,440 --> 00:20:09,520 CHRONIC PAIN AFTER TOTAL KNEE 441 00:20:09,520 --> 00:20:09,920 REPLACEMENT. 442 00:20:09,920 --> 00:20:13,560 SO, HEAL IS REALLY A PRETTY 443 00:20:13,560 --> 00:20:15,560 AMAZING PROGRAM FOR ANYONE THAT 444 00:20:15,560 --> 00:20:16,760 IS INTERESTED IN THE PAIN 445 00:20:16,760 --> 00:20:19,320 PROBLEM. WE DON'T HAVE AN 446 00:20:19,320 --> 00:20:22,240 INSTITUTE FOR PAIN. HEAL IS A 447 00:20:22,240 --> 00:20:24,360 PRETTY GOOD CONVENER FOR 448 00:20:24,360 --> 00:20:27,120 MULTIPLE ICS IN PAIN SPACE AND 449 00:20:27,120 --> 00:20:28,840 OFFERS THE ABILITY TO KIND OF 450 00:20:28,840 --> 00:20:32,320 MOVE THINGS FROM DISCOVERY PHASE 451 00:20:32,320 --> 00:20:34,080 TO ACTUALLY IMPROVE THE 452 00:20:34,080 --> 00:20:37,200 TREATMENT OF PATIENTS. 453 00:20:37,200 --> 00:20:38,600 REJOIN IS CLINICALLY IMPORTANT. 454 00:20:38,600 --> 00:20:40,640 IT IS A SPACE WHERE WE THINK 455 00:20:40,640 --> 00:20:43,360 LOTS OF ADVANCES COULD BE MADE 456 00:20:43,360 --> 00:20:45,360 BY DOUBLING DOWN ON THE KIND OF 457 00:20:45,360 --> 00:20:47,360 THINGS YOU FOLKS WERE TALKING 458 00:20:47,360 --> 00:20:48,800 ABOUT YESTERDAY AND REALLY 459 00:20:48,800 --> 00:20:50,840 UNDERSTANDING THE PAIN SYSTEM AT 460 00:20:50,840 --> 00:20:52,320 THE JOINT LEVEL AND WHOLE JOINT 461 00:20:52,320 --> 00:20:54,640 LEVEL WITH ALL OF THE RELEVANT 462 00:20:54,640 --> 00:20:56,240 TISSUES AND REALLY LOOKING 463 00:20:56,240 --> 00:20:57,800 FORWARD TO THE TALKS TODAY AND 464 00:20:57,800 --> 00:21:01,800 WORKING WITH YOU IN THE FUTURE. 465 00:21:01,800 --> 00:21:03,000 THANKS VERY MUCH. 466 00:21:03,000 --> 00:21:08,480 >>WELL, THANKS SO MUCH, DR. 467 00:21:08,480 --> 00:21:10,280 KOROSHETZ. WE REALLY APPRECIATE 468 00:21:10,280 --> 00:21:12,480 YOU JOINING US TODAY AND WILL 469 00:21:12,480 --> 00:21:14,280 INVITE YOU TO TURN BACK ON YOUR 470 00:21:14,280 --> 00:21:16,880 VIDEO SINCE I TURNED IT OFF FOR 471 00:21:16,880 --> 00:21:19,000 YOU. THANKS SO MUCH. WE ARE SO 472 00:21:19,000 --> 00:21:22,520 GLAD YOU COULD JOIN US. THANKS 473 00:21:22,520 --> 00:21:24,800 FOR THAT PRESENTATION TO REALLY 474 00:21:24,800 --> 00:21:26,720 SET THE TONE FOR TODAY AND HELP 475 00:21:26,720 --> 00:21:29,600 US BEGIN DAY 2 WITH SOME GREAT 476 00:21:29,600 --> 00:21:30,400 CONTEXT. 477 00:21:30,400 --> 00:21:34,200 NOW, I'M GOING TO TURN THINGS 478 00:21:34,200 --> 00:21:39,720 OVER TO OUR SESSION 4 CHAIRS AND 479 00:21:39,720 --> 00:21:42,720 SESSION 4 REMINDING YOU THIS IS 480 00:21:42,720 --> 00:21:44,360 INTERVENTIONS TO ADDRESS JOINT 481 00:21:44,360 --> 00:21:45,920 PAIN AND DISEASE AND CHAIR FOR 482 00:21:45,920 --> 00:21:49,560 THE SESSION IS DR. ALEX TUTLE OF 483 00:21:49,560 --> 00:21:54,040 NCCIH AND CO-CHAIRS ARE MICHAEL 484 00:21:54,040 --> 00:21:58,800 OF NINDS AND DR. KATHLEEN SLUKA 485 00:21:58,800 --> 00:22:01,160 WITH UNIVERSITY OF IOWA AND WE 486 00:22:01,160 --> 00:22:03,720 ARE PLEASED THEY WILL TAKE US 487 00:22:03,720 --> 00:22:04,640 THROUGH SESSION 4. 488 00:22:04,640 --> 00:22:06,880 ALSO, ALEX, DID YOU WANT TO GO 489 00:22:06,880 --> 00:22:09,280 AHEAD AND INTRODUCE OUR SPEAKERS 490 00:22:09,280 --> 00:22:11,840 FOR SESSION 4 AND OUR PANELISTS? 491 00:22:11,840 --> 00:22:14,720 PLEASE TAKE IT AWAY, ALEX. 492 00:22:14,720 --> 00:22:16,680 >>ABSOLUTELY. THANK YOU 493 00:22:16,680 --> 00:22:21,760 CATHERINE AND DR. KOROSHETZ FOR 494 00:22:21,760 --> 00:22:23,680 ILLUMINATING AND OPENING DAY 2 495 00:22:23,680 --> 00:22:26,280 OF THE WORKSHOP. -- AND CENTRAL 496 00:22:26,280 --> 00:22:29,800 NERVOUS SYSTEM IN WAYS THAT THE 497 00:22:29,800 --> 00:22:33,040 PERIPHERY CAN LEAD TO 498 00:22:33,040 --> 00:22:35,320 AFTERERIENT SIGNAL IN CENTRAL 499 00:22:35,320 --> 00:22:39,560 NERVOUS SYSTEM AND TARGETING 500 00:22:39,560 --> 00:22:41,320 THOSE AFTER FERANT SIGNAL IS 501 00:22:41,320 --> 00:22:42,480 SOMETHING TO THINK ABOUT OVER 502 00:22:42,480 --> 00:22:44,160 THE COURSE OF THE WORKSHOP AND 503 00:22:44,160 --> 00:22:48,640 PLEASURE TO INTRODUCE SESSION 4 504 00:22:48,640 --> 00:22:49,720 INTERVENTIONS TO ADDRESS JOINT 505 00:22:49,720 --> 00:22:51,880 PAIN AND DISEASE AND THANKS TO 506 00:22:51,880 --> 00:22:52,160 CO-CHAIRS. 507 00:22:52,160 --> 00:22:55,160 WE WILL HAVE FOLLOWING 508 00:22:55,160 --> 00:22:55,560 PRESENTATIONS. 509 00:22:55,560 --> 00:22:57,920 EXTERNAL CO-CHAIR DR. KATHLEEN 510 00:22:57,920 --> 00:23:00,280 SLUKA WILL GIVE THE FIRST TALK 511 00:23:00,280 --> 00:23:02,880 TODAY FROM UNIVERSITY OF IOWA 512 00:23:02,880 --> 00:23:05,800 FOLLOWED BY DAN RHON FROM 513 00:23:05,800 --> 00:23:08,240 UNIVERSITY OF HEALTH SCIENCES 514 00:23:08,240 --> 00:23:13,360 AND THEN FROM STEPHEN MESIER 515 00:23:13,360 --> 00:23:17,680 FROM WAIK FOREST AND PREETI FROM 516 00:23:17,680 --> 00:23:20,680 JOHNS HOPKINS AND PANELISTS 517 00:23:20,680 --> 00:23:27,880 TODAY INCLUDE DR. 518 00:23:27,880 --> 00:23:31,960 GUNNARBROLINSON AND KATIE 519 00:23:31,960 --> 00:23:36,440 BUTERA. 2K3W6789 ERTBRONFORT 520 00:23:36,440 --> 00:23:41,200 FROM UMN AND CHRISTINE GOERTZ 521 00:23:41,200 --> 00:23:43,640 AND BRIAN NOEHREN. I WELCOME 522 00:23:43,640 --> 00:23:47,600 YOU TO LOOK IN THE PROGRAM 523 00:23:47,600 --> 00:23:49,040 BOOKLET INCLUDED IN THE WORKSHOP 524 00:23:49,040 --> 00:23:52,600 TO SEE A FULL SUMMARY AND BIOAND 525 00:23:52,600 --> 00:23:54,680 RESEARCH INTEREST FROM ALL 526 00:23:54,680 --> 00:23:56,600 SPEAKERS AND PANELISTS TODAY AND 527 00:23:56,600 --> 00:23:59,840 WITH THAT INTRODUCING KATHLEEN 528 00:23:59,840 --> 00:24:02,200 SLUKA AND INVITE HER TO TAKE IT 529 00:24:02,200 --> 00:24:05,480 AWAY. THANK YOU DR. SLUKA. 530 00:24:05,480 --> 00:24:07,560 >>LET'S SEE IF I CAN DO THIS. 531 00:24:07,560 --> 00:24:12,200 ALL RIGHT. THANKS, ALEX, FOR 532 00:24:12,200 --> 00:24:14,360 PUTTING THIS TOGETHER AND 533 00:24:14,360 --> 00:24:15,920 INVITING ME TO PARTICIPATE. 534 00:24:15,920 --> 00:24:18,240 I WILL TRY TO SHARE MY SCREEN. 535 00:24:18,240 --> 00:24:20,440 SEE IF I CAN GET IT. 536 00:24:20,440 --> 00:24:25,040 ALL RIGHT. SO, I WILL TALK 537 00:24:25,040 --> 00:24:26,160 ABOUT TRANSCUTANEOUS SELECTIVE 538 00:24:26,160 --> 00:24:29,000 NERVE STIMULATION OR TENS AN OLD 539 00:24:29,000 --> 00:24:30,840 MODALITY THAT HAS BEEN AROUND 540 00:24:30,840 --> 00:24:32,600 SINCE -- IT HAS BEEN AROUND 541 00:24:32,600 --> 00:24:34,520 SINCE INVENTION OF ELECTRICITY 542 00:24:34,520 --> 00:24:36,360 IN ONE FORM OR ANOTHER AND CAME 543 00:24:36,360 --> 00:24:38,360 INTO MEDICAL ATTENTION IN THE 544 00:24:38,360 --> 00:24:40,160 1960S IN RESPONSE TO THE GATE 545 00:24:40,160 --> 00:24:42,840 CONTROLLED THEORY OF PAIN. I 546 00:24:42,840 --> 00:24:44,440 WON'T GIVE YOU A BIG LONG 547 00:24:44,440 --> 00:24:45,840 HISTORY BUT WILL SHOW YOU A 548 00:24:45,840 --> 00:24:49,080 LITTLE BIT ABOUT HOW IT WORKS 549 00:24:49,080 --> 00:24:56,680 AND TALK ABOUT CLINICAL 550 00:24:56,680 --> 00:24:58,680 LITERATURE AND WHY OR WHY IT MAY 551 00:24:58,680 --> 00:25:01,360 NOT SHOW EFFECTIVENESS IN 552 00:25:01,360 --> 00:25:03,040 CLINICAL CONDITIONS. 553 00:25:03,040 --> 00:25:05,360 I WILL ACKNOWLEDGE MY TEAM AND 554 00:25:05,360 --> 00:25:07,320 WORK I HAVE PRESENTED HAS BEEN A 555 00:25:07,320 --> 00:25:09,800 JOURNEY OF A COUPLE DECADES OF 556 00:25:09,800 --> 00:25:13,280 RESEARCH FROM VARIOUS DIFFERENT 557 00:25:13,280 --> 00:25:18,680 PEOPLE ACROSS THE WORLD WHO 558 00:25:18,680 --> 00:25:19,960 PARTICIPATED AND SUBSTANTIAL 559 00:25:19,960 --> 00:25:23,280 FUNDING FROM NATIONAL INSTITUTES 560 00:25:23,280 --> 00:25:24,040 OF HEALTH AND ARTHRITIS 561 00:25:24,040 --> 00:25:26,080 FOUNDATION. I HAVE A SLIDE ON 562 00:25:26,080 --> 00:25:27,600 MECHANISMS THAT I WANT TO 563 00:25:27,600 --> 00:25:28,720 SUMMARIZE IT. THESE WERE SERIES 564 00:25:28,720 --> 00:25:37,280 OF EXPERIMENTS WE HAVE DONG OVER 565 00:25:37,280 --> 00:25:41,360 MANY YEARS AND SHOWING THAT TENS 566 00:25:41,360 --> 00:25:45,320 DOES THIS PRIMARILY IN CENTRAL 567 00:25:45,320 --> 00:25:49,320 NERVOUS SYSTEM ENHANCING CENTRAL 568 00:25:49,320 --> 00:25:53,000 INHIBITION AND ACTIVATES 569 00:25:53,000 --> 00:25:54,400 DESCENDING INHIBITORY PATHWAYS. 570 00:25:54,400 --> 00:25:58,280 IN PARTICULAR, IT DOES IT IN A 571 00:25:58,280 --> 00:26:00,840 FREQUENCY DEPENDENT MANNER AND 572 00:26:00,840 --> 00:26:03,960 TENS COULD BE GIVEN AT LOW 573 00:26:03,960 --> 00:26:05,400 FREQUENCIES THAT IS 10 HERTZ OR 574 00:26:05,400 --> 00:26:10,560 LESS OR HIGH FREQUENCIES OF 60 575 00:26:10,560 --> 00:26:12,360 TO 150 HERTZ OF APPLIED 576 00:26:12,360 --> 00:26:14,000 STIMULATION TO THE SKIN AND 577 00:26:14,000 --> 00:26:16,480 PORTABLE DEVICES ARE OVER THE 578 00:26:16,480 --> 00:26:16,760 COUNTER. 579 00:26:16,760 --> 00:26:19,160 THEY ARE INEXPENSIVE AND EASY TO 580 00:26:19,160 --> 00:26:20,720 USE WITH MINIMAL SIDE-EFFECTS 581 00:26:20,720 --> 00:26:24,160 THAT I WILL SHOW YOU. 582 00:26:24,160 --> 00:26:26,800 HIGH FREQUENCY PRODUCES EFFECTS 583 00:26:26,800 --> 00:26:29,760 OF OPIOID RECEPTORS AT SITES AS 584 00:26:29,760 --> 00:26:33,360 WELL AND LOW FREQUENCY AT 585 00:26:33,360 --> 00:26:34,360 NEOOPIOID RECEPTORS AND ANOTHER 586 00:26:34,360 --> 00:26:36,080 NUMBER OF TRANSMITTERS 587 00:26:36,080 --> 00:26:38,600 DISCOVERED TO CONTRIBUTE TO ANAL 588 00:26:38,600 --> 00:26:40,520 GEEZIA AS WELL AND IN ADDITION 589 00:26:40,520 --> 00:26:43,560 TO ACTIVATING PATHWAYS IT 590 00:26:43,560 --> 00:26:46,280 REDUCES CENTRAL EXCITABILITY OR 591 00:26:46,280 --> 00:26:47,640 CENTRALIZATION WE HEARD ABOUT. 592 00:26:47,640 --> 00:26:50,760 SO, ALL STUDIES I SHOULD POINT 593 00:26:50,760 --> 00:26:53,360 OUT WERE DONE IN ANIMALS WITH 594 00:26:53,360 --> 00:26:55,560 JOINT INFLAMMATION AND WE KNOW 595 00:26:55,560 --> 00:26:57,400 THERE ARE CENTRAL SENSITIZATION 596 00:26:57,400 --> 00:27:00,800 AFTER JOINT INFLAMMATION AND 597 00:27:00,800 --> 00:27:02,680 TENS REDUCES SENSITIZATION BACK 598 00:27:02,680 --> 00:27:04,560 TOWARDS BASELINE LEVELS THAT IS 599 00:27:04,560 --> 00:27:07,360 A EXAMPLE OF A REPORTING FROM A 600 00:27:07,360 --> 00:27:09,080 HIGH THRESHOLD NEURON IN DORSAL 601 00:27:09,080 --> 00:27:10,280 [INDISCERNIBLE] AND YOU CAN SHOW 602 00:27:10,280 --> 00:27:12,320 BEFORE AND AFTER REDUCTION IN 603 00:27:12,320 --> 00:27:16,040 CENTRAL SENSITIVITY THAT REDUCES 604 00:27:16,040 --> 00:27:18,360 GLUTAMATE RELEASE AND GLIAL CELL 605 00:27:18,360 --> 00:27:20,720 ACTIVATION AND IS WORKING ON 606 00:27:20,720 --> 00:27:23,000 MULTIPLE PATHWAYS TO CHANGE THE 607 00:27:23,000 --> 00:27:24,280 CENTRAL NERVOUS SYSTEM. DESPITE 608 00:27:24,280 --> 00:27:27,320 KNOWING ALL THIS, SYSTEMATIC 609 00:27:27,320 --> 00:27:29,400 REVIEWS ARE A BIT MIXED. 610 00:27:29,400 --> 00:27:32,000 SOME SHOW EFFECTIVENESS AND SOME 611 00:27:32,000 --> 00:27:34,720 DON'T SHOW EFFECTIVENESS. 612 00:27:34,720 --> 00:27:37,360 AND I PUT LIKE LITTLE RED DOTS 613 00:27:37,360 --> 00:27:39,920 THAT CONCLUDED THAT TENS WAS 614 00:27:39,920 --> 00:27:41,880 EFFECTIVE AND GREEN DOTS TO SHOW 615 00:27:41,880 --> 00:27:43,280 THEY INCLUDED AN APPROPRIATE 616 00:27:43,280 --> 00:27:43,760 DOSE. 617 00:27:43,760 --> 00:27:45,640 ONE OF THE BIGGEST PROBLEMS WITH 618 00:27:45,640 --> 00:27:49,360 THE MIXED RESULTS AND IN FACT 619 00:27:49,360 --> 00:27:51,720 FOR OSTEOARTHRITIS, CLINICAL 620 00:27:51,720 --> 00:27:53,240 GUIDELINES RECOMMEND NOT USING 621 00:27:53,240 --> 00:27:54,720 TENS THAT I WILL SUGGEST TO YOU 622 00:27:54,720 --> 00:27:57,040 THAT IS MAYBE BASED ON SOME 623 00:27:57,040 --> 00:27:58,000 FLAWED LITERATURE. 624 00:27:58,000 --> 00:28:04,760 MOST OF THE STUDIES FOR A RATHER 625 00:28:04,760 --> 00:28:07,120 POOR QUALITY AND HIGH RISK OF 626 00:28:07,120 --> 00:28:07,320 BIAS. 627 00:28:07,320 --> 00:28:09,360 THEY HAD VERY LOW NUMBERS OF 628 00:28:09,360 --> 00:28:11,840 SUBJECTS IN RANDOMIZED 629 00:28:11,840 --> 00:28:13,360 CONTROLLED TRIALS AND MOST 630 00:28:13,360 --> 00:28:15,880 IMPORTANTLY MOST USE INADEQUATE 631 00:28:15,880 --> 00:28:17,720 DOSING AND DIDN'T TURN INTENSITY 632 00:28:17,720 --> 00:28:19,880 UP ENOUGH TO HAVE AN APPROPRIATE 633 00:28:19,880 --> 00:28:20,480 DOSE. 634 00:28:20,480 --> 00:28:23,760 THAT IS LIKE GIVING, SAY, 635 00:28:23,760 --> 00:28:26,360 MORPHINE AT A LOW DOSE THAT WE 636 00:28:26,360 --> 00:28:27,520 WOULDN'T EXPECT TO BE EFFECTIVE 637 00:28:27,520 --> 00:28:30,120 AND THEN ASKING WHETHER OR NOT 638 00:28:30,120 --> 00:28:32,440 IT WORKS OR THEY TIMED THE 639 00:28:32,440 --> 00:28:34,440 OUTCOME IN ODD WAYS AND GIVE THE 640 00:28:34,440 --> 00:28:37,360 TENS AND TWO WEEKS LATER ASKED 641 00:28:37,360 --> 00:28:38,840 DID IT WORK AND DOESN'T MAKE 642 00:28:38,840 --> 00:28:44,040 SENSE GIVEN WE KNOW THERE IS A 643 00:28:44,040 --> 00:28:44,800 PHARMACOLOGICAL MECHANISM OF 644 00:28:44,800 --> 00:28:46,280 ACTION. I WILL GO THROUGH A 645 00:28:46,280 --> 00:28:48,320 COUPLE OF EXAMPLES OF HOW OVER 646 00:28:48,320 --> 00:28:50,600 THE YEARS US AND OTHERS HAVE 647 00:28:50,600 --> 00:28:53,360 ADDRESSED THIS TO KIND OF SHOW 648 00:28:53,360 --> 00:28:56,120 YOU THAT THERE REALLY DOES 649 00:28:56,120 --> 00:28:57,480 MATTER HOW YOU GIVE IT, WHEN YOU 650 00:28:57,480 --> 00:29:00,000 GIVE IT, AND WHAT ARE FACTORS 651 00:29:00,000 --> 00:29:02,800 THAT EFFECT ITS EFFICACY. THE 652 00:29:02,800 --> 00:29:03,760 FIRST ONE IS DOSE. 653 00:29:03,760 --> 00:29:06,480 THIS IS HARD. WE HAVE TO THINK 654 00:29:06,480 --> 00:29:08,560 ABOUT INTENSITY AND THINK ABOUT 655 00:29:08,560 --> 00:29:09,320 FREQUENCY. WE HAVE TO THINK 656 00:29:09,320 --> 00:29:12,680 ABOUT ALL OF THE PARAMETERS OF 657 00:29:12,680 --> 00:29:13,520 ELECTRICAL STIMULATION AND WHERE 658 00:29:13,520 --> 00:29:15,240 DO YOU APPLY IT? 659 00:29:15,240 --> 00:29:17,360 IT TURNS OUT ONE OF THE MOST 660 00:29:17,360 --> 00:29:20,240 IMPORTANT FACTORS OF DOSING IS 661 00:29:20,240 --> 00:29:22,080 INTENSITY OF THE STIMULATION AND 662 00:29:22,080 --> 00:29:24,600 AS A NEUROPHARMACOLOGIST, I 663 00:29:24,600 --> 00:29:27,120 WANTED TO ACTUALLY DO A DOSE 664 00:29:27,120 --> 00:29:29,240 RESPONSE COURSE AND WE DID THREE 665 00:29:29,240 --> 00:29:31,560 DOSES OF TENS THAT YOU CAN SEE A 666 00:29:31,560 --> 00:29:37,520 NICE INCREASE ANAL GEEZIA WITH 667 00:29:37,520 --> 00:29:39,560 INCREASING DOSES AND DOSE WE 668 00:29:39,560 --> 00:29:43,160 GIVE IS STRONG SENSORY 669 00:29:43,160 --> 00:29:46,840 STIMULATION THAT IS STRONG BUT 670 00:29:46,840 --> 00:29:49,160 NOT PAINFUL. 671 00:29:49,160 --> 00:29:57,360 IN A SYSTEMATIC REVIEW DONE BY 672 00:29:57,360 --> 00:30:00,600 JOHN IN NORWAY WE DID LITERATURE 673 00:30:00,600 --> 00:30:02,640 ON POST-OP ITERATIVE PAIN AND 674 00:30:02,640 --> 00:30:06,160 PUT PEOPLE INTO WHETHER THEY HAD 675 00:30:06,160 --> 00:30:10,360 EFFECTIVE AND ADEQUATE DOSE OR 676 00:30:10,360 --> 00:30:13,360 INADEQUATE DOSE AND CONSUMPTION 677 00:30:13,360 --> 00:30:15,800 WAS ANALGESIC CONSUMPTION AND 678 00:30:15,800 --> 00:30:18,600 THOSE WITH INADEQUATE DOSE IT 679 00:30:18,600 --> 00:30:20,560 WAS NOT EFFECTIVE SUGGESTING WE 680 00:30:20,560 --> 00:30:22,360 HAVE TO LOOK AT ACTUAL 681 00:30:22,360 --> 00:30:24,240 LITERATURE AND DOSING 682 00:30:24,240 --> 00:30:25,480 REQUIREMENTS BEFORE WE DECIDE 683 00:30:25,480 --> 00:30:29,160 WHETHER OR NOT SOMETHING IS 684 00:30:29,160 --> 00:30:32,160 EFFECTIVE. 685 00:30:32,160 --> 00:30:34,120 TENS WORKS THROUGH OPIOIDS AND 686 00:30:34,120 --> 00:30:37,080 ASKED THE QUESTION WHAT HAPPENS? 687 00:30:37,080 --> 00:30:38,960 IS THERE INTERACTION WITH 688 00:30:38,960 --> 00:30:39,360 OPIOIDS? 689 00:30:39,360 --> 00:30:42,720 WHEN YOU GIVE TENS, THIS IS A 690 00:30:42,720 --> 00:30:45,360 KIND OF EXAMPLE OF AN ANIMAL 691 00:30:45,360 --> 00:30:47,360 MODEL WHERE YOU HAVE A THRESHOLD 692 00:30:47,360 --> 00:30:49,560 RESPONSE AND AFTER JOINT 693 00:30:49,560 --> 00:30:51,720 INFLAMMATION YOU GET DECREASE IN 694 00:30:51,720 --> 00:30:53,480 THRESHOLD AND HIGH OR LOW 695 00:30:53,480 --> 00:30:56,920 FREQUENCY IN TENS AND WE GET A 696 00:30:56,920 --> 00:30:58,640 FULL REVERSAL. IF WE GIVE EXACT 697 00:30:58,640 --> 00:31:01,360 SAME DOSE FOR SEVERAL DAYS WE 698 00:31:01,360 --> 00:31:03,560 GET ANALGESIC TOLERANCE AND BY 699 00:31:03,560 --> 00:31:06,280 DAY 4 IT IS NO LONGER WORKING IT 700 00:31:06,280 --> 00:31:09,360 IS WORKING IN OPIOID RECEPTORS 701 00:31:09,360 --> 00:31:12,760 IN CENTRAL NERVOUS SYSTEM AND 702 00:31:12,760 --> 00:31:14,440 THEY DEVELOP TOLERANCE TO THE 703 00:31:14,440 --> 00:31:14,680 OPIOID. 704 00:31:14,680 --> 00:31:25,200 IF YOU TAKE ANIMALS MAKING THEM 705 00:31:30,360 --> 00:31:33,240 TOLERANT TO OPIOIDS -- 706 00:31:33,240 --> 00:31:35,680 LASTLY WE DID A STUDY COMBINING 707 00:31:35,680 --> 00:31:38,400 LOW AND HIGH FREQUENCY OF TENS 708 00:31:38,400 --> 00:31:40,800 BASIC SCIENCE LITERATURE IF YOU 709 00:31:40,800 --> 00:31:43,560 GIVE IT SIMULTANEOUSLY IT 710 00:31:43,560 --> 00:31:45,080 REACHES ANALGESIC TOLERANCE AND 711 00:31:45,080 --> 00:31:48,440 ABLE TO MAINTAIN EFFICACY OUT 712 00:31:48,440 --> 00:31:50,880 WAY PAST THE 4 DAY TIME PERIOD 713 00:31:50,880 --> 00:31:53,120 BY GIVING MIXED FREQUENCIES AND 714 00:31:53,120 --> 00:31:55,560 WE ARE SAYING THIS IS ALSO PART 715 00:31:55,560 --> 00:31:57,560 OF DOSING CONSIDERATIONS. 716 00:31:57,560 --> 00:31:59,560 THE OTHER THING TO THINK ABOUT 717 00:31:59,560 --> 00:32:01,080 IS OUTCOME MEASUREMENT AND 718 00:32:01,080 --> 00:32:01,320 DESIGN. 719 00:32:01,320 --> 00:32:03,160 WHAT ARE WE MEASURING? 720 00:32:03,160 --> 00:32:06,440 LET'S TALK FIRST ABOUT THE 721 00:32:06,440 --> 00:32:09,320 TIMING OF THE OUTCOME IF YOU 722 00:32:09,320 --> 00:32:10,720 MEASURE DURING OR IMMEDIATELY 723 00:32:10,720 --> 00:32:14,680 AFTER TENS IT TENDS TO HAVE BEST 724 00:32:14,680 --> 00:32:15,840 EFFECT AND THOSE ARE LOW BACK 725 00:32:15,840 --> 00:32:19,440 PAIN SHOWED THERE WAS 726 00:32:19,440 --> 00:32:23,280 EFFECTIVENESS WHEN GIVEN AND 727 00:32:23,280 --> 00:32:25,360 MEASURED DURING TENS AND 1 TO 3 728 00:32:25,360 --> 00:32:27,480 MONTHS LATER IT DIDN'T WORK AND 729 00:32:27,480 --> 00:32:29,200 SHORT TERM EFFECT AND WORKS 730 00:32:29,200 --> 00:32:31,520 WHERE TENS UNIT IS ON OR 731 00:32:31,520 --> 00:32:32,720 IMMEDIATELY AFTER BUT NOT LATER. 732 00:32:32,720 --> 00:32:36,640 THIS IS AN ADEQUATELY POWERED 733 00:32:36,640 --> 00:32:38,440 SYSTEMATIC REVIEW FOR MARK 734 00:32:38,440 --> 00:32:39,800 JOHNSON WHERE HE TOOK ALL 735 00:32:39,800 --> 00:32:42,080 STUDIES ON PAIN AND TENS AND IN 736 00:32:42,080 --> 00:32:45,320 THIS CASE HE HAS 91RCTS WITH 737 00:32:45,320 --> 00:32:47,080 OVER 4 THOUSAND PEOPLE LOOKING 738 00:32:47,080 --> 00:32:50,400 AT TENS VERSUS PLACEBO AND TENS 739 00:32:50,400 --> 00:32:52,560 VERSUS NO TREATMENT AND TENS 740 00:32:52,560 --> 00:32:54,320 VERSUS STANDARD OF CARE THAT ALL 741 00:32:54,320 --> 00:32:57,320 SHOW EFFICACY. IF COMPARING TWO 742 00:32:57,320 --> 00:32:59,320 DIFFERENT TYPES OF TENS THEY 743 00:32:59,320 --> 00:33:00,880 WORK THE SAME. 744 00:33:00,880 --> 00:33:03,120 SO, HE IMPORTANTLY ONLY DID THIS 745 00:33:03,120 --> 00:33:05,400 DURING OR IMMEDIATELY AFTER TENS 746 00:33:05,400 --> 00:33:09,400 AND HE ONLY USED THOSE WHO HAD 747 00:33:09,400 --> 00:33:10,000 ADEQUATE INTENSITIES. 748 00:33:10,000 --> 00:33:13,200 SO, CONTENDING THAT IT MATTERS 749 00:33:13,200 --> 00:33:14,800 THAT WE USE THE RIGHT DOSE AND 750 00:33:14,800 --> 00:33:17,000 LOOK AT TIMING OF OUTCOME AND WE 751 00:33:17,000 --> 00:33:20,880 LOOK AT THE RIGHT OUTCOME. 752 00:33:20,880 --> 00:33:22,160 OKAY. WHAT IS THE RIGHT 753 00:33:22,160 --> 00:33:23,080 OUTCOME? 754 00:33:23,080 --> 00:33:24,720 IN A NUMBER OF DIFFERENT 755 00:33:24,720 --> 00:33:25,880 STUDIES, THERE HAS BEEN A NUMBER 756 00:33:25,880 --> 00:33:28,000 OF PEOPLE THAT LOOKED AT 757 00:33:28,000 --> 00:33:29,360 DIFFERENT TYPES OF OUTCOMES AND 758 00:33:29,360 --> 00:33:31,920 IS NOT PEOPLE WITH 759 00:33:31,920 --> 00:33:33,400 OSTEOARTHRITIS AND LOOKING AT 760 00:33:33,400 --> 00:33:35,640 PAIN THRESHOLDS AT THE KNEE, YOU 761 00:33:35,640 --> 00:33:38,920 SEE WE GET A NICE REDUCTION AT 762 00:33:38,920 --> 00:33:41,400 TENS AT KNEE JOINT AND PAIN 763 00:33:41,400 --> 00:33:43,040 PRESSURE THRESHOLDS AND IS 764 00:33:43,040 --> 00:33:45,600 LOOKING AT INDIVIDUALS WITH 765 00:33:45,600 --> 00:33:47,360 FIBROMYALGIA AND LOOKING AT 766 00:33:47,360 --> 00:33:48,840 RESTING PAIN VERSUS MOVEMENT 767 00:33:48,840 --> 00:33:50,800 PAIN YOU GET REDUCTION IN 768 00:33:50,800 --> 00:33:52,080 MOVEMENT NOT RESTING PAIN AND 769 00:33:52,080 --> 00:33:55,480 HOLDS TRUE IN OSTEOARTHRITIS AS 770 00:33:55,480 --> 00:33:57,680 WELL AND TENDS TO MOVE BETTER ON 771 00:33:57,680 --> 00:33:59,520 MOVEMENT PAIN AND THIS IS IN 772 00:33:59,520 --> 00:34:02,000 PEOPLE WITH NEUROPATHIC PAIN 773 00:34:02,000 --> 00:34:05,360 THAT IS REDUCING ALODINIA 774 00:34:05,360 --> 00:34:06,960 ASSOCIATED WITH NEUROPATHIC PAIN 775 00:34:06,960 --> 00:34:08,840 THAT ARE ALL INVOKED RESPONSES 776 00:34:08,840 --> 00:34:11,080 TO PAIN THAT MIGHT BE MORE 777 00:34:11,080 --> 00:34:13,360 EFFECTIVE ON THAT TYPE OF 778 00:34:13,360 --> 00:34:17,160 STIMULUS THAN IT IS ON RESTING 779 00:34:17,160 --> 00:34:17,480 PAIN. 780 00:34:17,480 --> 00:34:19,560 SO, I WANTED TO QUICKLY SHOW YOU 781 00:34:19,560 --> 00:34:22,600 ABOUT A STUDY THAT WE DID THAT 782 00:34:22,600 --> 00:34:26,880 WAS FUNDED BY NIAMS CALLED THE 783 00:34:26,880 --> 00:34:29,400 FAST STUDY. WE LOOKED AT TENS 784 00:34:29,400 --> 00:34:33,680 IN INDIVIDUALS WITH FIBROMYALGIA 785 00:34:33,680 --> 00:34:36,000 ADDRESSING THOSE FACTORS AND 786 00:34:36,000 --> 00:34:37,960 MIXED DOSE FREQUENCIES SO 787 00:34:37,960 --> 00:34:39,560 WOULDN'T GET TOLERANCE AND 788 00:34:39,560 --> 00:34:41,760 HIGHEST INTENSITY THEY COULD DO 789 00:34:41,760 --> 00:34:43,520 THAT WASN'T PAINFUL AND ASKED 790 00:34:43,520 --> 00:34:45,560 THEM TO WEAR TENS UNIT A COUPLE 791 00:34:45,560 --> 00:34:47,400 HOURS PER DAY AND USE IT WHEN 792 00:34:47,400 --> 00:34:49,600 ACTIVE AND PRIMARY OUTCOME WAS 793 00:34:49,600 --> 00:34:51,360 MOVEMENT EVOKED PAIN AND 794 00:34:51,360 --> 00:34:52,880 MEASURED IT DURING TENS AND 795 00:34:52,880 --> 00:34:55,480 AFTER A SINGLE OR ONE AND THEN 796 00:34:55,480 --> 00:34:57,760 WE SENT THEM HOME AND MEASURED 797 00:34:57,760 --> 00:34:59,080 AFTER ONE MONTH OF USE. 798 00:34:59,080 --> 00:35:01,360 WE HAD A BUNCH OF SECONDARY 799 00:35:01,360 --> 00:35:02,760 OUTCOMES THAT I PROBABLY WON'T 800 00:35:02,760 --> 00:35:03,360 TALK ABOUT. 801 00:35:03,360 --> 00:35:05,360 WE ADEQUATELY POWERED IT 802 00:35:05,360 --> 00:35:07,720 NOTICING WE HAD OVER 100 PEOPLE 803 00:35:07,720 --> 00:35:11,200 PER GROUP THAT IS RARE IN 804 00:35:11,200 --> 00:35:11,880 NON-PHARMACOLOGICAL RESEARCH TO 805 00:35:11,880 --> 00:35:14,400 HAVE HIGHLY POWERED LARGE SAMPLE 806 00:35:14,400 --> 00:35:14,640 SIZES. 807 00:35:14,640 --> 00:35:17,400 WE COMPARED TO ACTIVE TENS TO 808 00:35:17,400 --> 00:35:19,640 PLACEBO AND NO TENS WITH 809 00:35:19,640 --> 00:35:21,200 STANDARD OF CARE TREATMENT AND 810 00:35:21,200 --> 00:35:23,400 ALL PEOPLE WERE STILL TAKING 811 00:35:23,400 --> 00:35:25,080 MEDICATIONS AND DOING NORMAL 812 00:35:25,080 --> 00:35:26,520 THERAPIES. 813 00:35:26,520 --> 00:35:28,640 SO, WHAT WE WERE ABLE TO SHOW IS 814 00:35:28,640 --> 00:35:31,800 TENS REDUCED MOVEMENT PAIN. 815 00:35:31,800 --> 00:35:33,720 THIS FIRST SESSION ON VISIT 2 IS 816 00:35:33,720 --> 00:35:36,240 AFTER A SINGLE TREATMENT ON 817 00:35:36,240 --> 00:35:36,520 VISIT 3. 818 00:35:36,520 --> 00:35:39,640 THAT IS AFTER A MONTH OF 819 00:35:39,640 --> 00:35:39,960 TREATMENT. 820 00:35:39,960 --> 00:35:42,280 YOU CAN SEE THERE IS A NICE 821 00:35:42,280 --> 00:35:44,360 NEARLY 2 POINT REDUCTION IN 822 00:35:44,360 --> 00:35:46,760 MOVEMENT EVOKED PAIN MEASURED 823 00:35:46,760 --> 00:35:49,240 DURING 6 MINUTE WALK TEST OR SIT 824 00:35:49,240 --> 00:35:52,000 TO STAND TEST AND IS A 825 00:35:52,000 --> 00:35:52,960 SIGNIFICANT REDUCTION IN 826 00:35:52,960 --> 00:35:55,600 MOVEMENT EVOKED FATIGUE AND 827 00:35:55,600 --> 00:35:56,920 SMALLER BUT SIGNIFICANT 828 00:35:56,920 --> 00:35:58,120 REDUCTION IN RESTING PAIN. 829 00:35:58,120 --> 00:36:00,720 WHEN WE MEASURED IT WHILE TENS 830 00:36:00,720 --> 00:36:03,480 UNIT WAS ON, YOU CAN SEE A BIT 831 00:36:03,480 --> 00:36:07,280 OF A CUMULATIVE EFFECT WITH 832 00:36:07,280 --> 00:36:08,240 REPEATED USE. 833 00:36:08,240 --> 00:36:11,040 GIVEN THIS, WE MEASURED ADVERSE 834 00:36:11,040 --> 00:36:12,600 EVENTS AND I WANTED TO SHOW YOU 835 00:36:12,600 --> 00:36:13,920 THESE NUMBERS. 836 00:36:13,920 --> 00:36:17,080 SO, THIS IS NUMBER NEEDED TO 837 00:36:17,080 --> 00:36:18,760 TREAT AND NUMBER NEEDED TO HARM. 838 00:36:18,760 --> 00:36:21,360 I WILL LET YOU KNOW THAT IN 839 00:36:21,360 --> 00:36:23,120 CLINICAL STUDIES WITH 840 00:36:23,120 --> 00:36:25,280 PHARMACEUTICAL AGENTS APPROVED 841 00:36:25,280 --> 00:36:27,360 WITH FIBROMYALGIA NUMBER TO 842 00:36:27,360 --> 00:36:29,000 TREAT IS AROUND 8 OR 9 AND 843 00:36:29,000 --> 00:36:31,200 NUMBER TO HARM IS SIMILARLY IN 9 844 00:36:31,200 --> 00:36:34,200 TO 12 RANGE. 845 00:36:34,200 --> 00:36:37,240 YOU CAN SEE THAT OUR NUMBER 846 00:36:37,240 --> 00:36:38,760 NEEDED TO TREAT IS SOMEWHERE 847 00:36:38,760 --> 00:36:41,320 BETWEEN 4 AND 5 FOR PAIN AND 848 00:36:41,320 --> 00:36:43,440 FATIGUE WHEN COMPARED TO PLACEBO 849 00:36:43,440 --> 00:36:45,400 OR NO TENS GROUP AND NUMBER 850 00:36:45,400 --> 00:36:48,640 NEEDED TO HARM IS ESSENTIALLY 851 00:36:48,640 --> 00:36:50,440 NONEXIST YENLT AND WINDOW SERIES 852 00:36:50,440 --> 00:36:53,360 ADVERSE EVENTS IN ALL 300 PEOPLE 853 00:36:53,360 --> 00:36:57,000 AND WORSE ONES WE GOT WERE LIKE 854 00:36:57,000 --> 00:36:59,200 ITCHINESS AND SKIN IRRITATION 855 00:36:59,200 --> 00:37:01,200 AND ANXIETY WITH TENS THAT CAN 856 00:37:01,200 --> 00:37:03,160 BE ALLEVIATED BY REMOVING THE 857 00:37:03,160 --> 00:37:04,400 TENS. 858 00:37:04,400 --> 00:37:06,680 SO, I'M GOING TO SUMMARIZE BY 859 00:37:06,680 --> 00:37:09,840 SAYING THAT TENS IS SAFE AND IS 860 00:37:09,840 --> 00:37:12,080 EFFECTIVE AND INEXPENSIVE. IT 861 00:37:12,080 --> 00:37:14,080 IS A METHOD THAT A PATIENT COULD 862 00:37:14,080 --> 00:37:16,320 USE TO CONTROL THEIR PAIN DURING 863 00:37:16,320 --> 00:37:17,920 ACTIVITY TO HOPEFULLY ALLOW THEM 864 00:37:17,920 --> 00:37:20,600 TO BE MORE ACTIVE AND 865 00:37:20,600 --> 00:37:22,760 PARTICIPATE IN EFFECTIVE 866 00:37:22,760 --> 00:37:24,360 EXERCISE PROGRAMS. 867 00:37:24,360 --> 00:37:26,360 SO, WHAT I HAVE PREPARED OVER 868 00:37:26,360 --> 00:37:29,880 THE LAST TWO SLIDES THAT I WILL 869 00:37:29,880 --> 00:37:32,720 THROW OUT THERE FOR DISCUSSION. 870 00:37:32,720 --> 00:37:34,200 BUT, MY RECOMMENDATIONS ARE THAT 871 00:37:34,200 --> 00:37:37,400 WE NEED FUTURE CLINICAL TRIALS 872 00:37:37,400 --> 00:37:41,280 THAT TAKE ALL OF THESE 873 00:37:41,280 --> 00:37:42,480 CONSIDERATIONS INTO THE TRIAL 874 00:37:42,480 --> 00:37:44,280 ITSELF AND NEED TO THINK ABOUT 875 00:37:44,280 --> 00:37:46,040 THE TIMING OF THE OUTCOME AND 876 00:37:46,040 --> 00:37:47,800 DOING IT DURING OR IMMEDIATELY 877 00:37:47,800 --> 00:37:48,520 AFTER TENS. 878 00:37:48,520 --> 00:37:51,320 WE NEED TO THINK ABOUT THE 879 00:37:51,320 --> 00:37:52,920 INTENSITY OF STIMULATION MAKING 880 00:37:52,920 --> 00:37:54,840 SURE IT IS A STRONG BUT 881 00:37:54,840 --> 00:37:55,880 COMFORTABLE INTENSITY. 882 00:37:55,880 --> 00:37:58,000 WE HAVE TO THINK ABOUT SAMPLE 883 00:37:58,000 --> 00:37:58,240 SIZES. 884 00:37:58,240 --> 00:38:01,760 I WILL CONTENT THAT WE NEED, YOU 885 00:38:01,760 --> 00:38:03,400 KNOW, RATHER LARGE SAMPLE SIZES 886 00:38:03,400 --> 00:38:05,200 SO THEY COULD BE TRANSFERRED TO 887 00:38:05,200 --> 00:38:07,840 THE GREATER POPULATION BETTER 888 00:38:07,840 --> 00:38:11,040 AND WE MIGHT NEED MULTISIGHT 889 00:38:11,040 --> 00:38:12,680 TRIALS TO DO THIS OR PRAGMATIC 890 00:38:12,680 --> 00:38:14,840 TRIALS TO DO THIS AND NEED 891 00:38:14,840 --> 00:38:16,360 PRAGMATIC TRIALS TO GET THIS 892 00:38:16,360 --> 00:38:18,120 INTO THE CLINIC MORE AND USED TO 893 00:38:18,120 --> 00:38:20,080 BE USED AND NOT USED BECAUSE 894 00:38:20,080 --> 00:38:21,280 PEOPLE DON'T THINK IT IS 895 00:38:21,280 --> 00:38:23,320 EFFECTIVE AND NOW KNOWING THAT 896 00:38:23,320 --> 00:38:24,280 SCIENCE IS COMING BACK A LITTLE 897 00:38:24,280 --> 00:38:26,680 BIT AND KNOW MORE IT IS BEING 898 00:38:26,680 --> 00:38:27,920 PICKED UP A LITTLE BIT MORE. 899 00:38:27,920 --> 00:38:30,320 WE NEED TO CONTROL FOR ALL RISKS 900 00:38:30,320 --> 00:38:33,920 AND BIAS IN TRIALS. 901 00:38:33,920 --> 00:38:36,800 MEASURE AND REPORT ADVERSE 902 00:38:36,800 --> 00:38:39,760 EVENTS THAT GOES FOR ALL 903 00:38:39,760 --> 00:38:40,400 NON-PHARMACOLOGICAL TREATMENTS 904 00:38:40,400 --> 00:38:42,440 AND NEED TO DO THIS AND DO A 905 00:38:42,440 --> 00:38:44,200 RESPONDER ANALYSIS WE DID IN THE 906 00:38:44,200 --> 00:38:45,920 STUDY THAT I DON'T HAVE TIME TO 907 00:38:45,920 --> 00:38:46,720 TALK ABOUT IT TODAY. 908 00:38:46,720 --> 00:38:49,000 WE HAVE TO FIGURE OUT WHO WILL 909 00:38:49,000 --> 00:38:50,760 BE BEST RESPONDER TO THIS 910 00:38:50,760 --> 00:38:52,400 TREATMENT TO MOVE THEM FORWARD. 911 00:38:52,400 --> 00:38:54,720 NOBODY RESPONDS TO EVERY 912 00:38:54,720 --> 00:38:56,240 TREATMENT. 913 00:38:56,240 --> 00:38:57,880 [INDISCERNIBLE] THIS IS REALLY 914 00:38:57,880 --> 00:38:59,920 PROBLEMATIC AND SYSTEMATIC 915 00:38:59,920 --> 00:39:01,280 REVIEWS WE TEND TO INCLUDE EVERY 916 00:39:01,280 --> 00:39:03,400 STUDY EVER PUBLISHED IN THE 917 00:39:03,400 --> 00:39:05,040 AREA. REMEMBER, THESE STUDIES 918 00:39:05,040 --> 00:39:07,400 HAVE BEEN GOING ON SINCE 1960S 919 00:39:07,400 --> 00:39:10,000 AND CLINICAL TRIAL METHODOLOGY 920 00:39:10,000 --> 00:39:12,160 HAS GREATLY IMPROVED SINCE 1960S 921 00:39:12,160 --> 00:39:14,680 THAT I WOULD SAY IS MUCH MORE 922 00:39:14,680 --> 00:39:16,400 ROBUST TODAY THAN IT WAS EVEN 20 923 00:39:16,400 --> 00:39:17,280 YEARS AGO. 924 00:39:17,280 --> 00:39:20,080 SO, WE SHOULD BE LOOKING AT NOT 925 00:39:20,080 --> 00:39:21,680 ONLY INCLUDING THINGS THAT ARE 926 00:39:21,680 --> 00:39:24,080 RELATED TO DOSE AND TIMING OF 927 00:39:24,080 --> 00:39:25,840 OUTCOMES AND SAMPLE SIZE. WE 928 00:39:25,840 --> 00:39:28,680 SHOULD ALSO BE LOOKING AT 929 00:39:28,680 --> 00:39:30,800 THINKING ABOUT SHOULD WE BE 930 00:39:30,800 --> 00:39:32,440 INCLUDING OLDER TRIALS THAT MAY 931 00:39:32,440 --> 00:39:35,360 OR MAY NOT HAVE USED ADEQUATE 932 00:39:35,360 --> 00:39:37,640 BLINDING AND ADEQUATE CONTROL 933 00:39:37,640 --> 00:39:40,240 FOR ADEQUATE RISK OF BIAS IN 934 00:39:40,240 --> 00:39:40,480 THOSE. 935 00:39:40,480 --> 00:39:44,080 SHOULD WE BE DOING METAANALYSIS 936 00:39:44,080 --> 00:39:48,400 ON SAMPLES OF 100, SHOULD WE 937 00:39:48,400 --> 00:39:49,400 WAIT UNTIL WE HAVE LARGE ENOUGH 938 00:39:49,400 --> 00:39:52,000 POOL OF SAMPLE SIZE LIKE MARK 939 00:39:52,000 --> 00:39:54,080 JOHNSON DID WITH HIS AND INCLUDE 940 00:39:54,080 --> 00:39:55,720 RTCS WITH SMALL SAMPLE SIZES OR 941 00:39:55,720 --> 00:39:58,360 WAIT UNTIL WE HAVE ENOUGH RTCS 942 00:39:58,360 --> 00:40:00,680 WITH ADEQUATE SAMPLE SIZES TO 943 00:40:00,680 --> 00:40:02,160 INCLUDE IN THESE AND SMALL 944 00:40:02,160 --> 00:40:05,360 SAMPLE SIZES, YOU KNOW, PUT US 945 00:40:05,360 --> 00:40:08,520 IN A POSITION OF HAVING FALSE 946 00:40:08,520 --> 00:40:10,080 POSITIVES AND FALSE NEGATIVES 947 00:40:10,080 --> 00:40:13,360 AND IT -- IT IS DIFFICULT TO 948 00:40:13,360 --> 00:40:14,920 INTERPRET THE DATA. 949 00:40:14,920 --> 00:40:17,400 >>ALL RIGHT. DR. SLUKA, WE 950 00:40:17,400 --> 00:40:19,160 HAVE TO MOVE TO THE NEXT 951 00:40:19,160 --> 00:40:21,600 SPEAKER. THANKS VERY MUCH. 952 00:40:21,600 --> 00:40:23,440 >>ALL RIGHT. THAT IS IT. 953 00:40:23,440 --> 00:40:24,000 THANK YOU. 954 00:40:24,000 --> 00:40:25,160 >>THANK YOU. 955 00:40:25,160 --> 00:40:26,400 >>YOU DIDN'T GIVE A WARNING. 956 00:40:26,400 --> 00:40:28,000 >>WE WILL MAKE SURE WE ARE 957 00:40:28,000 --> 00:40:29,960 DOING IT FOR FOLT OWING 958 00:40:29,960 --> 00:40:30,240 SPEAKERS. 959 00:40:30,240 --> 00:40:31,920 >>OKAY. SORRY ABOUT THAT. 960 00:40:31,920 --> 00:40:35,040 >>NO, NO, NO. THANK YOU VERY 961 00:40:35,040 --> 00:40:39,120 MUCH. DR. RHON? 962 00:40:39,120 --> 00:40:40,200 THANK YOU VERY MUCH. 963 00:40:40,200 --> 00:40:46,400 >>HERE WE GO. ALL RIGHT. I'M 964 00:40:46,400 --> 00:40:48,320 GRATEFUL FOR THE INVITATION AND 965 00:40:48,320 --> 00:40:49,800 OPPORTUNITY TO SHARE A LITTLE 966 00:40:49,800 --> 00:40:53,560 BIT ABOUT OUR WORK LOOKING AT 967 00:40:53,560 --> 00:40:55,440 MANUAL THERAPY FOR TREATING 968 00:40:55,440 --> 00:40:58,960 LOWER EXTREMITY OSTEOARTHRITIS 969 00:40:58,960 --> 00:41:00,840 IN PARTICULAR KNEE 970 00:41:00,840 --> 00:41:02,480 OSTEOARTHRITIS AND LOOK AT THE 971 00:41:02,480 --> 00:41:03,680 EFFECTIVENESS AND PROBABLY NOT 972 00:41:03,680 --> 00:41:06,400 AS MUCH THE PROPOSED MECHANISMS 973 00:41:06,400 --> 00:41:09,360 JUST BECAUSE THIS TIME PERIOD IS 974 00:41:09,360 --> 00:41:10,320 REALLY SHORT. 975 00:41:10,320 --> 00:41:13,200 LET'S SEE. THERE WE GO. 976 00:41:13,200 --> 00:41:13,560 DISCLAIMERS. 977 00:41:13,560 --> 00:41:16,560 BURDEN OF KNEE OSTEOARTHRITIS 978 00:41:16,560 --> 00:41:21,880 AND THINK WHY WE CHOSEN THIS 979 00:41:21,880 --> 00:41:25,400 CONDITION GLOBALLY 291 980 00:41:25,400 --> 00:41:26,520 CONDITIONS HIP [INDISCERNIBLE] 981 00:41:26,520 --> 00:41:29,160 RANKED HIGHEST CONTRIBUTOR TO 982 00:41:29,160 --> 00:41:31,600 GLOBAL DISABILITY AND 3 EIGHTH 983 00:41:31,600 --> 00:41:32,800 HIGHEST DISABILITY ADJUSTED IN 984 00:41:32,800 --> 00:41:35,960 LIFE YEARS AND LOOKING AT JUST 985 00:41:35,960 --> 00:41:38,360 NORTH AMERICA IT IS EIGHTH MOST 986 00:41:38,360 --> 00:41:40,320 EXPENSIVE OUT OF 154 HEALTH 987 00:41:40,320 --> 00:41:43,400 CONDITIONS TO MANAGE. 988 00:41:43,400 --> 00:41:45,880 SO, SOMETHING THAT REALLY NEEDS 989 00:41:45,880 --> 00:41:48,800 TO TAKE SOME OF OUR ATTENTION. 990 00:41:48,800 --> 00:41:50,880 IT IS HELPFUL TO START WITH SOME 991 00:41:50,880 --> 00:41:55,240 WORKING DEFINITIONS OF MANUAL 992 00:41:55,240 --> 00:41:55,560 THERAPY. 993 00:41:55,560 --> 00:41:59,240 THIS IS A SYSTEMATIC REVIEW DONE 994 00:41:59,240 --> 00:42:04,240 BY SOME OF MY STUDENTS FOR 995 00:42:04,240 --> 00:42:08,040 REVIEW AND BACK PAIN OUT OF 996 00:42:08,040 --> 00:42:10,840 176RCTS THERE WAS 169 UNIQUE 997 00:42:10,840 --> 00:42:14,840 TERMS LABELED AS MANUAL THERAPY. 998 00:42:14,840 --> 00:42:17,040 IF LOOGING AT -- THEIR 999 00:42:17,040 --> 00:42:18,960 DEFINITION OF MANUAL THERAPIES 1000 00:42:18,960 --> 00:42:20,720 INCLUDING TRIGGER POINT DRY 1001 00:42:20,720 --> 00:42:24,640 NEEDLING, CUPPING, 1002 00:42:24,640 --> 00:42:27,080 INSTRUMENT-ASSISTED DEVICES AND 1003 00:42:27,080 --> 00:42:30,840 MASSAGE AND ALL OF THESE THINGS. 1004 00:42:30,840 --> 00:42:33,360 A LOT OF THE TRIALS FOR LOW BACK 1005 00:42:33,360 --> 00:42:36,640 PAIN AND NECK PAIN LESS THAN 5% 1006 00:42:36,640 --> 00:42:38,360 PROVIDED ANY SORT OF LEVEL OF 1007 00:42:38,360 --> 00:42:40,040 DESCRIPTION THAT ALLOWED IT TO 1008 00:42:40,040 --> 00:42:41,760 BE REPRODUCED. 1009 00:42:41,760 --> 00:42:43,880 SO, BECAUSE OF THIS, I THINK IT 1010 00:42:43,880 --> 00:42:45,360 IS JUST AN IMPORTANT STEP BACK 1011 00:42:45,360 --> 00:42:48,400 AND LOOK AT THIS HOW WE DEFINE 1012 00:42:48,400 --> 00:42:49,600 MANUAL THERAPY AS MORE OF A 1013 00:42:49,600 --> 00:42:51,120 TREATMENT APPROACH. 1014 00:42:51,120 --> 00:42:54,920 SO, IT IS AN INTEGRATION OF 1015 00:42:54,920 --> 00:42:57,160 ACTIVE AND PASSIVE STRATEGY AND 1016 00:42:57,160 --> 00:43:00,440 WHOLE PURPOSE OF THE MANUAL 1017 00:43:00,440 --> 00:43:03,680 THERAPY APPROACH IS TO GET THE 1018 00:43:03,680 --> 00:43:06,400 PATIENT TO MOVE BETTER AND MORE 1019 00:43:06,400 --> 00:43:08,160 EXERCISE AND WE KNOW PHYSICAL 1020 00:43:08,160 --> 00:43:09,400 ACTIVITY IS A CORE INTERVENTION 1021 00:43:09,400 --> 00:43:11,240 THAT IS RECOMMENDED IN MOST 1022 00:43:11,240 --> 00:43:14,800 CLINICAL PRACTICE GUIDELINES FOR 1023 00:43:14,800 --> 00:43:17,920 OSTEOARTHRITIS. PATIENTS WILL 1024 00:43:17,920 --> 00:43:20,080 COME IN. 1025 00:43:20,080 --> 00:43:22,360 THERE IS A LOT OF MOTIONS WITH 1026 00:43:22,360 --> 00:43:24,320 EXERCISE AND REGULAR 1027 00:43:24,320 --> 00:43:25,360 PHYSIOLOGICAL MOTIONS AND 1028 00:43:25,360 --> 00:43:26,600 FLEXION EXTENSION AND WHAT NOT. 1029 00:43:26,600 --> 00:43:29,000 THEY ARE PROBABLY ABLE TO GET 1030 00:43:29,000 --> 00:43:32,000 LOTS OF ACCESSORY MOTIONS IN 1031 00:43:32,000 --> 00:43:35,640 THAT JOINT GETS STIFFER AND 1032 00:43:35,640 --> 00:43:37,800 ANTERIOR AND POSTERIOR TIBULAR 1033 00:43:37,800 --> 00:43:41,200 ROTATION AND THOSE TYPES OF 1034 00:43:41,200 --> 00:43:43,600 THINGS CAN BENEFIT FROM MANUALLY 1035 00:43:43,600 --> 00:43:45,400 ASSISTED MOBILIZATIONS AND POINT 1036 00:43:45,400 --> 00:43:47,400 IS WITH PATIENTS WHAT A SECTION 1037 00:43:47,400 --> 00:43:49,760 MIGHT LOOK LIKE THEY COME IN AND 1038 00:43:49,760 --> 00:43:52,680 DO A FUNCTIONAL SQUAT AND THEY 1039 00:43:52,680 --> 00:43:57,520 HAVE PAIN AND WE MOBILIZE TIBIO 1040 00:43:57,520 --> 00:44:00,960 FEMORAL JOINT AND REDUCE PAIN 1041 00:44:00,960 --> 00:44:02,440 AND HAVE THEM SQUAT A LOT BETTER 1042 00:44:02,440 --> 00:44:04,920 AND TRANSITION INTO ACTIVITY AND 1043 00:44:04,920 --> 00:44:07,560 EXERCISE AND OVER A COURSE OF 1044 00:44:07,560 --> 00:44:09,960 PHYSICAL THERAPY AND 8 TO 10 1045 00:44:09,960 --> 00:44:11,480 SESSIONS AND FIRST COUPLE 1046 00:44:11,480 --> 00:44:13,360 SESSIONS MIGHT HAVE MORE 1047 00:44:13,360 --> 00:44:14,600 MANUALLY APPLIED INTERVENTIONS 1048 00:44:14,600 --> 00:44:17,400 THAT NEAR THE END THEY ARE 1049 00:44:17,400 --> 00:44:19,600 EXERCISING MORE AND FALLING 1050 00:44:19,600 --> 00:44:21,320 CLINICAL REASONING FRAMEWORK AND 1051 00:44:21,320 --> 00:44:23,360 TUNE UP BOOSTER VISITS AND GOAL 1052 00:44:23,360 --> 00:44:27,080 OF THIS IS TO GET PATIENTS TO 1053 00:44:27,080 --> 00:44:32,880 MOVE MORE AND BE ACTIVE GET 1054 00:44:32,880 --> 00:44:34,160 BENEFITS OF PHYSICAL ACTIVITY 1055 00:44:34,160 --> 00:44:36,280 AND EXERCISE AND RESEARCH 1056 00:44:36,280 --> 00:44:37,760 STARTED BACK WITH FIRST 1057 00:44:37,760 --> 00:44:40,160 PUBLICATION BACK IN YEAR 2000. 1058 00:44:40,160 --> 00:44:41,960 AND WHERE -- WHERE MANUAL 1059 00:44:41,960 --> 00:44:45,400 PHYSICAL THERAPY WAS COMPARED TO 1060 00:44:45,400 --> 00:44:47,040 PLACEBO ULTRA SOUND. 1061 00:44:47,040 --> 00:44:50,000 AND SUBTHERAPEUTIC ULTRA SOUND. 1062 00:44:50,000 --> 00:44:55,480 WE COULD SEE EFFECT SIZES HERE. 1063 00:44:55,480 --> 00:45:01,360 IT WAS EFFECTIVE WOMBAC 1064 00:45:01,360 --> 00:45:02,800 OSTEOARTHRITIS INDEX AND 1065 00:45:02,800 --> 00:45:03,880 [INDISCERNIBLE] COMPARED TO 1066 00:45:03,880 --> 00:45:06,680 PLACEBO AND IMPROVEMENTS IN 6 1067 00:45:06,680 --> 00:45:09,360 MINUTE WALK TEST A FEW YEARS 1068 00:45:09,360 --> 00:45:12,120 LATER ANOTHER FOLLOW ON TRIAL 1069 00:45:12,120 --> 00:45:13,520 THIS TIME COMPARING MANUAL 1070 00:45:13,520 --> 00:45:15,360 PHYSICAL THERAPY TO EXERCISE 1071 00:45:15,360 --> 00:45:16,560 PROGRAM AND HOME EXERCISE 1072 00:45:16,560 --> 00:45:18,600 PROGRAM AND THEY WOULD COME IN 1073 00:45:18,600 --> 00:45:20,640 AND GET EXERCISES PRESCRIBED AND 1074 00:45:20,640 --> 00:45:22,760 BE ABLE TO DEMONSTRATE. THEY 1075 00:45:22,760 --> 00:45:24,560 COULD DO IT AND KEPT A LOG AT 1076 00:45:24,560 --> 00:45:27,520 HOME AND ABLE TO FOLLOW UP WITH 1077 00:45:27,520 --> 00:45:29,000 PHYSICAL THERAPISTS. 1078 00:45:29,000 --> 00:45:31,600 WITH BOTH INTERVENTIONS YOU SAW 1079 00:45:31,600 --> 00:45:33,560 MANUAL PHYSICAL THERAPY THAT WAS 1080 00:45:33,560 --> 00:45:36,000 ROUGHLY ABOUT 8 SESSIONS THAT 1081 00:45:36,000 --> 00:45:38,840 WAS ONE OF THE OVERALL TREATMENT 1082 00:45:38,840 --> 00:45:39,240 DOSE. 1083 00:45:39,240 --> 00:45:41,520 YOU COULD SEE IT WAS 1084 00:45:41,520 --> 00:45:43,160 SIGNIFICANTLY -- THERE WAS A 1085 00:45:43,160 --> 00:45:44,760 GOOD EFFECT SIZE THERE COMPARED 1086 00:45:44,760 --> 00:45:46,560 TO HOME EXERCISE PROGRAM AND 1087 00:45:46,560 --> 00:45:48,880 FAST FORWARD A FEW YEARS. 1088 00:45:48,880 --> 00:45:50,600 THIS PAPER THAT CAME OUT WHERE 1089 00:45:50,600 --> 00:45:53,800 WE LOOKED AT INJECTION STEROID 1090 00:45:53,800 --> 00:45:55,480 INJECTION AND LOOKED AT 1091 00:45:55,480 --> 00:45:57,720 LITERATURE AND FOUND THAT, YOU 1092 00:45:57,720 --> 00:46:00,280 KNOW, ROUGHLY A LOT MORE 1093 00:46:00,280 --> 00:46:02,440 PATIENTS GETS INJECTIONS AND 1094 00:46:02,440 --> 00:46:04,560 ROUGHLY 50% ACROSS THE BOARD 1095 00:46:04,560 --> 00:46:07,080 THAT IS A COMMON INTERVENTION 1096 00:46:07,080 --> 00:46:09,080 DOING COMPARATIVE EFFECTIVENESS 1097 00:46:09,080 --> 00:46:11,200 TRIAL TO SEE LET'S COMPARE THIS 1098 00:46:11,200 --> 00:46:12,360 TO MANUAL PHYSICAL THERAPY 1099 00:46:12,360 --> 00:46:14,000 APPROACH SEEING WHAT DIFFERENCES 1100 00:46:14,000 --> 00:46:15,640 ARE AND MAYBE THIS WILL HELP 1101 00:46:15,640 --> 00:46:17,640 WITH THE UPTAKE OF THIS. AGAIN, 1102 00:46:17,640 --> 00:46:19,720 WE SAW IT WAS EFFECTIVE THAT IS 1103 00:46:19,720 --> 00:46:21,600 LONG TERM OUT TO ONE YEAR AND 1104 00:46:21,600 --> 00:46:23,880 DID COST EFFECTIVENESS ANALYSIS. 1105 00:46:23,880 --> 00:46:26,360 ISSUE IS LOTS OF PATIENTS THINK 1106 00:46:26,360 --> 00:46:28,400 THAT THEY HAVE -- THEY WILL ONLY 1107 00:46:28,400 --> 00:46:31,240 GET ONE INJECTION THAT IS ONE 1108 00:46:31,240 --> 00:46:32,200 VISIT COMING IN TO PHYSICAL 1109 00:46:32,200 --> 00:46:33,920 THERAPY AND TAKES A LITTLE MORE 1110 00:46:33,920 --> 00:46:36,320 TIME AND MAYBE A LITTLE -- A FEW 1111 00:46:36,320 --> 00:46:38,680 MORE OUT OF POCKET COSTS AND IN 1112 00:46:38,680 --> 00:46:40,320 THE SHORT TERM COULD BE MORE 1113 00:46:40,320 --> 00:46:42,440 COSTLY. HOWEVER, WE FOUND THAT 1114 00:46:42,440 --> 00:46:44,360 THE MEDIAN NUMBER OF INJECTIONS 1115 00:46:44,360 --> 00:46:46,560 THAT PEOPLE ACTUALLY ENDED UP 1116 00:46:46,560 --> 00:46:48,560 HAVING. LOTS OF PEOPLE COME 1117 00:46:48,560 --> 00:46:52,200 BACK HAVING MORE AND 2.3 1118 00:46:52,200 --> 00:46:54,160 INJECTIONS OR -- SO, A LOT OF 1119 00:46:54,160 --> 00:46:55,560 PEOPLE COME IN GETTING 1120 00:46:55,560 --> 00:46:59,200 ADDITIONAL INJECTIONS AND WAS 4 1121 00:46:59,200 --> 00:47:01,200 INDIVIDUALS THAT HAD SURGERY 1122 00:47:01,200 --> 00:47:02,160 BETWEEN ARTHROSCOPY AND TOTAL 1123 00:47:02,160 --> 00:47:05,000 KNEE REPLACEMENT IN INJECTION 1124 00:47:05,000 --> 00:47:06,760 GROUP AND 0 IN PHYSICAL THERAPY 1125 00:47:06,760 --> 00:47:08,800 GROUP AND OVER PERIOD OF A YEAR, 1126 00:47:08,800 --> 00:47:11,320 FOLLOW UP, THERE IS MORE UP 1127 00:47:11,320 --> 00:47:13,160 FRONT COSTS THAT MIGHT ACTUALLY 1128 00:47:13,160 --> 00:47:16,640 BE CHEAPER IN THE LONG RUN. YOU 1129 00:47:16,640 --> 00:47:18,520 MIGHT UTILIZE LESS HEALTH CARE 1130 00:47:18,520 --> 00:47:19,560 AND INTERESTING IS STABILITY OF 1131 00:47:19,560 --> 00:47:24,320 THIS EFFECT. YOU CAN SEE IN 1132 00:47:24,320 --> 00:47:25,600 BLACK THERE, THERE ARE TWO 1133 00:47:25,600 --> 00:47:27,440 TRIALS SUPERIMPOSED FIRST ONES 1134 00:47:27,440 --> 00:47:30,080 IN 2000 AND 2005 AND RED LINE IS 1135 00:47:30,080 --> 00:47:34,160 MOST RECENT ONE THAT IS A STABLE 1136 00:47:34,160 --> 00:47:35,200 INTERVENTION THAT ALMOST A 20 1137 00:47:35,200 --> 00:47:36,880 YEAR PERIOD IN DIFFERENT TRIALS 1138 00:47:36,880 --> 00:47:39,480 THAT HAS HAD A VERY SIMILAR AND 1139 00:47:39,480 --> 00:47:40,400 VERY STABLE EFFECT SIZE. 1140 00:47:40,400 --> 00:47:43,600 IF YOU COULD TAKE THIS EFFECT 1141 00:47:43,600 --> 00:47:44,720 SIZE WITH SUCH MINIMAL 1142 00:47:44,720 --> 00:47:46,800 SIDE-EFFECTS AND PUT IT IN A 1143 00:47:46,800 --> 00:47:49,720 BOTTLE AND MARKET THIS, 1144 00:47:49,720 --> 00:47:51,360 PHARMACEUTICAL INDUSTRY WOULD BE 1145 00:47:51,360 --> 00:47:53,000 VERY, VERY EXCITED ABOUT 1146 00:47:53,000 --> 00:47:54,440 TREATMENT EFFECTS YOU ARE ABLE 1147 00:47:54,440 --> 00:47:56,360 TO SEE WITH THIS. 1148 00:47:56,360 --> 00:47:58,360 SO, WHEN WE TALK ABOUT, YOU 1149 00:47:58,360 --> 00:48:01,000 KNOW, WHY THIS WORKS, REAL 1150 00:48:01,000 --> 00:48:02,920 QUICKLY, THERE IS -- THIS COULD 1151 00:48:02,920 --> 00:48:05,400 BE A WHOLE OTHER TALK IN AND OF 1152 00:48:05,400 --> 00:48:06,920 ITSELF AND KNOW THAT EXERCISE 1153 00:48:06,920 --> 00:48:09,920 AND PHYSICAL ACTIVITY IS THE 1154 00:48:09,920 --> 00:48:11,000 CORE RECOMMENDATION INTERVENTION 1155 00:48:11,000 --> 00:48:13,960 THAT PATIENTS WITH KNEE 1156 00:48:13,960 --> 00:48:15,440 OSTEOARTHRITIS SHOULD BE 1157 00:48:15,440 --> 00:48:17,160 RECEIVING AND ONE OF THE 1158 00:48:17,160 --> 00:48:18,720 CHALLENGES IS THAT TOO MUCH 1159 00:48:18,720 --> 00:48:20,840 LOADING OF THE JOINT THAT IS 1160 00:48:20,840 --> 00:48:22,440 TYPICALLY THE CONCERN AND TOO 1161 00:48:22,440 --> 00:48:23,280 MANY COMPRESSION FORCES. 1162 00:48:23,280 --> 00:48:25,600 THEY CAN -- THEY CAN MAKE THE 1163 00:48:25,600 --> 00:48:26,840 JOINT WORSE. 1164 00:48:26,840 --> 00:48:29,120 ALSO, UNDERLOADING THE JOINT IS 1165 00:48:29,120 --> 00:48:31,280 ALSO SEEMING TO BE EQUALLY IF 1166 00:48:31,280 --> 00:48:34,800 NOT MORE SORT OF THESE CATABOLIC 1167 00:48:34,800 --> 00:48:37,800 EFFECTS OF THE -- THE JOINT CART 1168 00:48:37,800 --> 00:48:39,600 LITH. 1169 00:48:39,600 --> 00:48:41,640 THAT IS ONE OF THE BIGGEST 1170 00:48:41,640 --> 00:48:42,000 CHALLENGES. 1171 00:48:42,000 --> 00:48:44,320 WE HAVE REALLY A LOT OF EVIDENCE 1172 00:48:44,320 --> 00:48:47,040 CONTRARY TO PROBABLY PATIENT 1173 00:48:47,040 --> 00:48:48,240 BELIEFS AND CLINICIAN BELIEFS. 1174 00:48:48,240 --> 00:48:52,160 YOU KNOW, WE ARE PROBABLY ON THE 1175 00:48:52,160 --> 00:48:54,360 ERRING ON THE SIDE OF DOING TOO 1176 00:48:54,360 --> 00:48:56,840 LITTLE RATHER THAN DOING TOO 1177 00:48:56,840 --> 00:48:58,920 MUCH AND MIGHT BE PROTECTIVE FOR 1178 00:48:58,920 --> 00:49:01,360 KNEE OSTEOARTHRITIS IN SOME 1179 00:49:01,360 --> 00:49:04,400 CASES AND HIGHER INTENSITY 1180 00:49:04,400 --> 00:49:05,760 STRENGTH TRAINING THAT LOADED 1181 00:49:05,760 --> 00:49:07,560 THE JOINT WASN'T ANY WORSE THAN 1182 00:49:07,560 --> 00:49:09,320 LOWER INTENSITY STRENGTH 1183 00:49:09,320 --> 00:49:09,680 TRAINING. 1184 00:49:09,680 --> 00:49:12,440 SO, THESE ARE MESSAGES THAT 1185 00:49:12,440 --> 00:49:14,120 PATIENTS ARE PROBABLY NOT 1186 00:49:14,120 --> 00:49:15,320 GETTING AND LOTS OF CLINICIANS 1187 00:49:15,320 --> 00:49:17,400 ARE NOT GETTING AND YOU TEND TO 1188 00:49:17,400 --> 00:49:19,080 BE A LITTLE MORE RISK AVERSE AND 1189 00:49:19,080 --> 00:49:21,440 NOT WANT TO DO A LOT OF 1190 00:49:21,440 --> 00:49:21,840 ACTIVITY. 1191 00:49:21,840 --> 00:49:24,040 GETTING INTO MECHANISMS OF PAIN 1192 00:49:24,040 --> 00:49:26,160 REDUCTION. AGAIN, THIS CAN BE 1193 00:49:26,160 --> 00:49:28,200 PRETTY COMPLEX AND WOULD POINT 1194 00:49:28,200 --> 00:49:33,280 YOU TO SOME WORK DONE BY JOE 1195 00:49:33,280 --> 00:49:35,040 BILOSKI. HE PROPOSED MECHANISMS 1196 00:49:35,040 --> 00:49:37,920 FROM PAIN MODULATION AND MANUAL 1197 00:49:37,920 --> 00:49:39,920 THERAPY. REALLY IS A GREAT AND 1198 00:49:39,920 --> 00:49:41,240 INTERESTING STUFF THERE. AGAIN, 1199 00:49:41,240 --> 00:49:43,200 I WON'T GET INTO DETAILS TOO 1200 00:49:43,200 --> 00:49:43,960 MUCH. 1201 00:49:43,960 --> 00:49:46,480 BUT, I WOULD JUST PROPOSE THAT 1202 00:49:46,480 --> 00:49:48,440 MAYBE THE -- THAT IS NOT THE 1203 00:49:48,440 --> 00:49:48,720 PROBLEM. 1204 00:49:48,720 --> 00:49:51,120 YOU KNOW, THE PROBLEM IS NOT TO 1205 00:49:51,120 --> 00:49:52,440 QUESTION. SOLUTION IS NOT THE 1206 00:49:52,440 --> 00:49:53,040 ANSWER. 1207 00:49:53,040 --> 00:49:55,680 SO, NOT TO GET TOO PHILOSOPHICAL 1208 00:49:55,680 --> 00:49:59,560 HERE AND TO STEAL FROM THE MATH 1209 00:49:59,560 --> 00:50:00,840 LITERATURE TO FIND THIS TOPIC. 1210 00:50:00,840 --> 00:50:04,120 YOU KNOW, HOW MANY PATIENTS WITH 1211 00:50:04,120 --> 00:50:05,920 OA IN UNITED STATES RECEIVE 1212 00:50:05,920 --> 00:50:08,560 PHYSICAL THERAPY AND NEOA AND 1213 00:50:08,560 --> 00:50:12,120 PRIOR TO GETTING A JOINT 1214 00:50:12,120 --> 00:50:13,360 REPLACEMENT THAT IS ULTIMATE 1215 00:50:13,360 --> 00:50:15,000 TREATMENT AND WON'T WAIT ON 1216 00:50:15,000 --> 00:50:17,200 ANSWERS SINCE WE ARE SHORT ON 1217 00:50:17,200 --> 00:50:19,120 TIME AND 10 TO 15% GOING TO 1218 00:50:19,120 --> 00:50:21,400 PHYSICAL THERAPY AND POINT THEY 1219 00:50:21,400 --> 00:50:24,320 GET KNEE REPLACEMENT IT ENTO 15% 1220 00:50:24,320 --> 00:50:25,760 TRY OR HAD PHYSICAL THERAPY AT 1221 00:50:25,760 --> 00:50:27,640 SOME POINT. I THINK IT IS 1222 00:50:27,640 --> 00:50:29,120 OUTRAGEOUS AND NO THE THAT WE -- 1223 00:50:29,120 --> 00:50:31,880 WE KNOW WHAT WORKS AND MAYBE THE 1224 00:50:31,880 --> 00:50:34,040 QUESTION IS HOW TO GET PEOPLE TO 1225 00:50:34,040 --> 00:50:34,760 UTILIZE IT. 1226 00:50:34,760 --> 00:50:36,760 LOOKING AT UTILIZATION OF 1227 00:50:36,760 --> 00:50:38,320 PHYSICAL THERAPY AND SEE THAT 1228 00:50:38,320 --> 00:50:40,480 REFERRAL RATES ARE LESS THAN 5% 1229 00:50:40,480 --> 00:50:42,880 FOR PRIMARY CARE. THEY HAVE 1230 00:50:42,880 --> 00:50:45,320 BEEN GOING DOWN BETWEEN 2007 AND 1231 00:50:45,320 --> 00:50:48,440 2015 AND A LITTLE BETTER FOR 1232 00:50:48,440 --> 00:50:51,680 ORTHOPEDIC SURGEONS 9 TO 15%. 1233 00:50:51,680 --> 00:50:53,800 THAT IS A BIG PROBLEM. AT THE 1234 00:50:53,800 --> 00:50:56,120 SAME TIME, PHARMACEUTICAL 1235 00:50:56,120 --> 00:50:57,240 INTERVENTIONS HAVE BEEN GOING 1236 00:50:57,240 --> 00:50:59,320 UP, YOU KNOW, SUBSTANTIALLY IN 1237 00:50:59,320 --> 00:51:00,320 THE SAME PERIOD. 1238 00:51:00,320 --> 00:51:03,760 SO, YOU KNOW, WHEN YOU LOOK AT 1239 00:51:03,760 --> 00:51:05,040 COCHRAN REVIEW MIXED METHODS 1240 00:51:05,040 --> 00:51:09,360 THAT IS REALLY INTERESTING AND 1241 00:51:09,360 --> 00:51:10,920 PEOPLE BELIEFS ABOUT CHRONIC 1242 00:51:10,920 --> 00:51:13,360 PAIN AND HOW TO MANAGE PAIN AND 1243 00:51:13,360 --> 00:51:15,160 KNEES ARE DELICATE AS A 1244 00:51:15,160 --> 00:51:17,360 CONSEQUENCE. YOU KNOW, THEY 1245 00:51:17,360 --> 00:51:19,160 AVOID ACTIVITY FOR FEAR OF 1246 00:51:19,160 --> 00:51:20,440 CAUSING HARM. THEY NEED TO 1247 00:51:20,440 --> 00:51:23,120 REALLY PROVIDE ASSURANCE AND 1248 00:51:23,120 --> 00:51:24,640 CLEAR ADVICE ABOUT VALUE OF 1249 00:51:24,640 --> 00:51:26,960 EXERCISE AND PAPER WAS REALLY 1250 00:51:26,960 --> 00:51:31,000 INTERESTING IN CLINICAL 1251 00:51:31,000 --> 00:51:33,400 ORTHOPEDICS -- WAITING TO GET 1252 00:51:33,400 --> 00:51:35,240 KNEE REPLACEMENT INTERVIEWED 1253 00:51:35,240 --> 00:51:38,160 BONE ON BONE BELIEFS IDENTITY 1254 00:51:38,160 --> 00:51:40,680 BELIEFS AND MOST BELIEVED THAT 1255 00:51:40,680 --> 00:51:42,760 LOADING KNEE WOULD MAKE THEM 1256 00:51:42,760 --> 00:51:44,120 VULNERABLE AND EXERCISE PHYSICAL 1257 00:51:44,120 --> 00:51:45,760 THERAPY WOULD INCREASE PAIN AND 1258 00:51:45,760 --> 00:51:46,680 MAKE THEM WORSE. 1259 00:51:46,680 --> 00:51:50,080 THEY PREFERRED SURGICAL AND 1260 00:51:50,080 --> 00:51:51,360 EXPERIMENTAL TREATMENTS OVER, 1261 00:51:51,360 --> 00:51:53,040 YOU KNOW, LOTS OF EXERCISES. 1262 00:51:53,040 --> 00:51:55,160 YOU CAN SEE HERE IN THE LITTLE 1263 00:51:55,160 --> 00:51:57,800 FIGURE HERE THAT WEAR AND TEAR 1264 00:51:57,800 --> 00:51:58,400 AND BONE ON BONE. 1265 00:51:58,400 --> 00:52:01,320 >>IN A MINUTE. OKAY? 1266 00:52:01,320 --> 00:52:03,040 >>THEY GO TO THEIR TREATMENT 1267 00:52:03,040 --> 00:52:04,840 BELIEFS AND LEAD THEM TO THE 1268 00:52:04,840 --> 00:52:06,840 POINT THAT SURGERY IS REALLY THE 1269 00:52:06,840 --> 00:52:07,320 ONLY OPTION. 1270 00:52:07,320 --> 00:52:09,600 WHY AM I GOING TO GO TO PHYSICAL 1271 00:52:09,600 --> 00:52:11,200 THERAPY AND DO EXERCISE THAT 1272 00:52:11,200 --> 00:52:13,040 WILL ONLY GET IT WORSE? 1273 00:52:13,040 --> 00:52:14,880 SO, THERE IS SOME POTENTIAL FOR 1274 00:52:14,880 --> 00:52:17,760 LOW UPTAKE BOTH FROM THE PATIENT 1275 00:52:17,760 --> 00:52:19,560 BELIEFS PERSPECTIVE BUT FROM THE 1276 00:52:19,560 --> 00:52:20,720 CLINICIAN. I THINK THE QUESTION 1277 00:52:20,720 --> 00:52:21,920 IS NOT WHAT WORKS. 1278 00:52:21,920 --> 00:52:24,160 WE HAVE A REALLY POWERFUL 1279 00:52:24,160 --> 00:52:25,360 INTERVENTION. AGAIN, IT WON'T 1280 00:52:25,360 --> 00:52:27,520 WORK FOR EVERYONE, BUT IF WE 1281 00:52:27,520 --> 00:52:31,000 ONLY HAVE 10 TO 15% OF PATIENTS 1282 00:52:31,000 --> 00:52:31,840 GETTING THIS INTERVENTION BEFORE 1283 00:52:31,840 --> 00:52:35,160 THEY GO AND HAVE A KNEE JOINT 1284 00:52:35,160 --> 00:52:36,560 REPLACEMENT THERE IS ROOM FOR 1285 00:52:36,560 --> 00:52:39,200 IMPROVEMENT AND GETTING UPTAKE 1286 00:52:39,200 --> 00:52:40,440 UTILIZATION FOR WHAT WE KNOW 1287 00:52:40,440 --> 00:52:40,640 WORKS. 1288 00:52:40,640 --> 00:52:43,720 AS A DAD, I HAVE TO THROW IN A 1289 00:52:43,720 --> 00:52:47,000 LITTLE DAD JOKE THERE. THANK 1290 00:52:47,000 --> 00:52:48,080 YOU. 1291 00:52:48,080 --> 00:52:50,960 >>THANK YOU SO MUCH. 1292 00:52:50,960 --> 00:52:55,880 DR. MESSIER, YOU ARE WELCOME TO 1293 00:52:55,880 --> 00:52:59,320 SHARE YOUR SLIDES. 1294 00:52:59,320 --> 00:53:09,840 >>OKAY. CAN ANYONE SEE THAT? 1295 00:53:18,880 --> 00:53:23,240 >>YES. WE CAN SEE YOU. YUP. 1296 00:53:23,240 --> 00:53:24,520 >>OKAY. 1297 00:53:24,520 --> 00:53:27,040 >>ALL RIGHT. WELL, FIRST, 1298 00:53:27,040 --> 00:53:29,360 THANKS FOR INVITING ME HERE FOR 1299 00:53:29,360 --> 00:53:30,800 THIS WONDERFUL WORK SHOP. I 1300 00:53:30,800 --> 00:53:31,880 REALLY APPRECIATE IT. BEFORE WE 1301 00:53:31,880 --> 00:53:34,480 GET GOING, I WOULD LIKE TO 1302 00:53:34,480 --> 00:53:35,880 ACKNOWLEDGE AN OUTSTANDING GROUP 1303 00:53:35,880 --> 00:53:38,560 OF INVESTIGATORS. 1304 00:53:38,560 --> 00:53:41,920 WELL, OBESITY AND JOINT PAIN ARE 1305 00:53:41,920 --> 00:53:42,240 RELATED. 1306 00:53:42,240 --> 00:53:44,920 AS OBESITY INCREASES FROM 1307 00:53:44,920 --> 00:53:49,160 OVERWEIGHT TO CLASS 3 OBESITY, 1308 00:53:49,160 --> 00:53:50,800 ODDS RATIO IS FOR JOINT PAIN 1309 00:53:50,800 --> 00:53:51,480 INCREASE. 1310 00:53:51,480 --> 00:53:53,480 FOR EXAMPLE, FEMALES WITH CLASS 1311 00:53:53,480 --> 00:53:56,680 3 OBESITY ARE FOUR TIMES AS 1312 00:53:56,680 --> 00:54:00,440 LIKELY TO HAVE JOINT PAIN AS 1313 00:54:00,440 --> 00:54:02,000 FEMALES WITH NORMAL WEIGHT. 1314 00:54:02,000 --> 00:54:04,240 ABOUT HALF OF ALL OF THE WOMEN 1315 00:54:04,240 --> 00:54:08,520 WITH CLASS 2 OR CLASS 3 OBESITY 1316 00:54:08,520 --> 00:54:12,080 SHOWN HERE IN THE PURPLE BARS 1317 00:54:12,080 --> 00:54:12,760 REPORTS SUBSTANTIAL JOINT PAIN 1318 00:54:12,760 --> 00:54:20,480 THAT THIS INCREASES WITH AGE. 1319 00:54:20,480 --> 00:54:23,680 DOES GEOGRAPHY MATTER? 1320 00:54:23,680 --> 00:54:25,240 WELL, APPARENTLY, IT DOES. 1321 00:54:25,240 --> 00:54:29,360 PEOPLE WITH OBESITY AND KNEE 1322 00:54:29,360 --> 00:54:30,840 OSTEOARTHRITIS LIVING IN RURAL 1323 00:54:30,840 --> 00:54:32,480 COMMUNITIES HAVE SIGNIFICANTLY 1324 00:54:32,480 --> 00:54:34,480 MORE JOINT PAIN THAN A SIMILAR 1325 00:54:34,480 --> 00:54:41,360 COHORT THAT LIVES IN URBAN 1326 00:54:41,360 --> 00:54:46,720 COMMUNITIES OBESITY IS 1327 00:54:46,720 --> 00:54:48,400 ASSOCIATED WITH JOINT PAIN. 1328 00:54:48,400 --> 00:54:51,160 GEOGRAPHY MATTERS THOSE WITH 1329 00:54:51,160 --> 00:54:52,880 NEO-A AND OBESITY LIVING IN 1330 00:54:52,880 --> 00:54:55,000 RURAL COMMUNITIES REPORT MORE 1331 00:54:55,000 --> 00:54:56,560 JOINT PAIN THAN THOSE PEOPLE WHO 1332 00:54:56,560 --> 00:54:59,280 LIVE IN MORE URBAN AREAS. 1333 00:54:59,280 --> 00:55:01,200 THE TWO MOST COMMON EXERCISES IN 1334 00:55:01,200 --> 00:55:04,040 TRIALS OF ADULTS WITH KNEE PAIN 1335 00:55:04,040 --> 00:55:06,760 ARE WALKING AND TO A LESSER 1336 00:55:06,760 --> 00:55:10,280 EXTENT, WEIGHT TRAIN. FITNESS 1337 00:55:10,280 --> 00:55:11,520 ARTHRITIS AND SENIORS TRIAL SHOW 1338 00:55:11,520 --> 00:55:15,520 THAT 18 MONTHS OF EITHER AEROBIC 1339 00:55:15,520 --> 00:55:17,720 WALKING EXERCISE OR RESISTANCE 1340 00:55:17,720 --> 00:55:19,880 EXERCISE SLOWED PROGRESSION AND 1341 00:55:19,880 --> 00:55:21,200 DISABILITY THAT IS COMMON IN 1342 00:55:21,200 --> 00:55:24,000 OLDER ADULTS WITH KNEE 1343 00:55:24,000 --> 00:55:25,880 OSTEOARTHRITIS COMPARED TO 1344 00:55:25,880 --> 00:55:28,320 HEALTH EDUCATION CONTROL GROUP 1345 00:55:28,320 --> 00:55:33,400 AND HELP ESTABLISH EXERCISE 1346 00:55:33,400 --> 00:55:35,400 STANDARD OF CARE FOR PEOPLE WITH 1347 00:55:35,400 --> 00:55:37,400 KNEE OSTEOARTHRITIS. 1348 00:55:37,400 --> 00:55:41,560 WEIGHT TRAINING GROUP IN AEROBIC 1349 00:55:41,560 --> 00:55:43,040 WALKING GROUP HAD SIGNIFICANTLY 1350 00:55:43,040 --> 00:55:44,920 LESS PAIN INTENSITY AFTER 18 1351 00:55:44,920 --> 00:55:48,920 MONTHS COMPARED TO HEALTH 1352 00:55:48,920 --> 00:55:59,440 EDUCATION THAN CONTROL GROUP. 1353 00:56:01,640 --> 00:56:03,600 -- 1354 00:56:03,600 --> 00:56:05,560 SHOWING THAT 12 WEEKS OF 1355 00:56:05,560 --> 00:56:06,680 [INDISCERNIBLE] STRENGTH 1356 00:56:06,680 --> 00:56:08,280 TRAINING SIGNIFICANTLY DECREASE 1357 00:56:08,280 --> 00:56:12,320 KNEE PAIN VERSUS CONTROL IN KNEE 1358 00:56:12,320 --> 00:56:13,800 OSTEOARTHRITIS PATIENTS AND 1359 00:56:13,800 --> 00:56:16,160 STRENGTH TRAINING FOR ARTHRITIS 1360 00:56:16,160 --> 00:56:19,440 TRIAL OR START RANDOMIZE 377 1361 00:56:19,440 --> 00:56:21,760 PARTICIPANTS TO ONE OF 3 GROUPS 1362 00:56:21,760 --> 00:56:24,080 AND HIGH INTENSITY STRENGTH 1363 00:56:24,080 --> 00:56:26,120 TRAINING, LOW INTENSITY STRENGTH 1364 00:56:26,120 --> 00:56:28,200 TRAINING OR RETENTION CONTROL 1365 00:56:28,200 --> 00:56:29,640 AND ALL THREE INTERVENTIONS WERE 1366 00:56:29,640 --> 00:56:35,280 18 MONTHS IN DURATION PERCENT 1367 00:56:35,280 --> 00:56:37,400 REDUCTION IN PLAIN WAS LOW OF 2 1368 00:56:37,400 --> 00:56:39,680 SEVEN% FOR HIGH INTENSITY 1369 00:56:39,680 --> 00:56:41,240 STRENGTH TRAINING GROUP TO HIGH 1370 00:56:41,240 --> 00:56:43,600 OF 39% FOR LOW INTENSITY 1371 00:56:43,600 --> 00:56:45,560 STRENGTH TRAINING GROUP WITH 1372 00:56:45,560 --> 00:56:46,920 CONTROL GROUP BEING IN-BETWEEN 1373 00:56:46,920 --> 00:56:53,760 WITH TLE 3% REDUCTION IN PAIN. 1374 00:56:53,760 --> 00:56:57,400 PERCENT OF PATIENTS USING PAIN 1375 00:56:57,400 --> 00:56:59,320 MEDICATION DECREASED ACROSS ALL 1376 00:56:59,320 --> 00:57:01,440 THREE GRIPES AND LOW INTENSITY 1377 00:57:01,440 --> 00:57:02,960 PATIENTS WERE 3 TIMES MORE 1378 00:57:02,960 --> 00:57:05,080 LIKELY NOT TO USE PAIN 1379 00:57:05,080 --> 00:57:09,080 MEDICATION BY 18 MONTH FOLLOW UP 1380 00:57:09,080 --> 00:57:11,680 VERSUS THE CONTROL. 1381 00:57:11,680 --> 00:57:14,240 RECOMMENDATIONS SUGGEST THAT 1382 00:57:14,240 --> 00:57:18,920 EXERCISE COMPARED FAB RABLY TO 1383 00:57:18,920 --> 00:57:20,520 ACETAMINOPHEN AND EFFECT SIZE 1384 00:57:20,520 --> 00:57:22,680 FOR PAIN. HOWEVER, EFFECT SIZE 1385 00:57:22,680 --> 00:57:30,400 FOR EXERCISE DECLINE IN PEOPLE 1386 00:57:30,400 --> 00:57:33,800 WITH KNEE KNEE OSTEOARTHRITIS AS 1387 00:57:33,800 --> 00:57:37,680 SAMPLE SIZE AT THE TIME 1388 00:57:37,680 --> 00:57:40,240 DECREASES FROM TWO MONTHS WITH 1389 00:57:40,240 --> 00:57:43,320 EFFECT SIZE OF .54 ALL THE WAY 1390 00:57:43,320 --> 00:57:47,880 DOWN TO AN EFFECT SIZE OF .09 1391 00:57:47,880 --> 00:57:52,200 FOR 18-MONTH INTERVENTION. 1392 00:57:52,200 --> 00:57:54,960 THIS MAY HELP EXPLAIN RESULTS OF 1393 00:57:54,960 --> 00:57:58,520 A RECENT SYSTEMATIC REVIEW AND 1394 00:57:58,520 --> 00:58:00,160 METAANALYSIS AND FIRST PLOT 1395 00:58:00,160 --> 00:58:01,360 SHOWS DIFFERENCE BETWEEN 1396 00:58:01,360 --> 00:58:04,600 EXERCISE AND CONTROL ON 0 TO 100 1397 00:58:04,600 --> 00:58:05,280 SCALE. 1398 00:58:05,280 --> 00:58:08,200 OVERALL, THERE WAS A MODEST 1399 00:58:08,200 --> 00:58:11,720 DIFFERENCE OF ABOUT 3.4 POINTS 1400 00:58:11,720 --> 00:58:15,520 AND 3.4% FAVORING IMPROVEMENT IN 1401 00:58:15,520 --> 00:58:15,840 PAIN. 1402 00:58:15,840 --> 00:58:19,080 HOWEVER, THIS DIFFERENCE IS OF 1403 00:58:19,080 --> 00:58:21,960 QUESTIONABLE CLINICAL 1404 00:58:21,960 --> 00:58:22,880 IMPORTANCE. 1405 00:58:22,880 --> 00:58:25,520 SO, THEN EXERCISE AND OBESITY. 1406 00:58:25,520 --> 00:58:27,960 EXERCISE REDUCES JOINT PAIN IN 1407 00:58:27,960 --> 00:58:31,560 PEOPLE WITH OBESITY AND KNEE 1408 00:58:31,560 --> 00:58:33,280 OSTEOARTHRITIS AND EFFECT SIZE 1409 00:58:33,280 --> 00:58:35,760 DECREASES AS LENGTH OF 1410 00:58:35,760 --> 00:58:36,800 INTERVENTION INCREASES. 1411 00:58:36,800 --> 00:58:38,400 NUMEROUS STUDY SHOWS EXERCISE 1412 00:58:38,400 --> 00:58:40,640 HAS MANY POSITIVE EFFECTS. 1413 00:58:40,640 --> 00:58:42,320 HOWEVER, LONG-TERM EFFECT ON 1414 00:58:42,320 --> 00:58:49,080 PAIN IN THIS POPULATION IS MOD 1415 00:58:49,080 --> 00:58:51,600 EST AND OF UNCERTAIN CLINICAL 1416 00:58:51,600 --> 00:58:53,560 IMPORTANCE AND MECHANISTIC MODEL 1417 00:58:53,560 --> 00:58:57,360 SHOWS WEIGHT LO S AND EXERCISE 1418 00:58:57,360 --> 00:58:59,040 IMPACT BIOMECHANICAL AND 1419 00:58:59,040 --> 00:59:01,240 INFLAMMATORY DISEASE PATHWAYS 1420 00:59:01,240 --> 00:59:02,960 RESULTING IN DECREASE KNEE JOINT 1421 00:59:02,960 --> 00:59:06,040 LOANS AND DECREASE IN 1422 00:59:06,040 --> 00:59:07,560 INFLAMMATORY CYTOKINE ACTIVITY 1423 00:59:07,560 --> 00:59:10,480 AND DECREASE IN TISSUE DAMAGE 1424 00:59:10,480 --> 00:59:11,760 AND [INDISCERNIBLE] AND LESS 1425 00:59:11,760 --> 00:59:12,160 [INDISCERNIBLE]. 1426 00:59:12,160 --> 00:59:13,720 ALL RESULTING IN WHAT IS 1427 00:59:13,720 --> 00:59:16,560 IMPORTANT TO THE PATIENT IS A 1428 00:59:16,560 --> 00:59:18,760 DECREASE IN PAIN. 1429 00:59:18,760 --> 00:59:21,760 AND IMPROVED FUNCTION. 1430 00:59:21,760 --> 00:59:23,840 INTENSIVE DIET AND EXERCISE FOR 1431 00:59:23,840 --> 00:59:26,280 ARTHRITIS TRIAL OR IDEA HAD 1432 00:59:26,280 --> 00:59:28,000 THREE INTERVENTION BOOTHS AND 1433 00:59:28,000 --> 00:59:30,120 EXERCISE IN COMPARISON GROUP AND 1434 00:59:30,120 --> 00:59:32,680 DIET ONLY GROUP AND DIET PLUS 1435 00:59:32,680 --> 00:59:34,760 EXERCISE GROUP AND DIET GOING 1436 00:59:34,760 --> 00:59:37,960 FOR TWO DIET GROUPS AT LEAST A 1437 00:59:37,960 --> 00:59:40,920 10% WEIGHT LOSS OVER 18 MONTH 1438 00:59:40,920 --> 00:59:41,240 INTERVENTION. 1439 00:59:41,240 --> 00:59:43,600 THIS IS A MONTH BY MONTH WEIGHT 1440 00:59:43,600 --> 00:59:47,080 LOSS FOR DIET ONLY AND DIET PLUS 1441 00:59:47,080 --> 00:59:47,840 ASKER SIZE GROUP. 1442 00:59:47,840 --> 00:59:49,760 YOU CAN SEE ADDITION OF EXERCISE 1443 00:59:49,760 --> 00:59:53,640 TO DIET ADDS 2% MORE IN WEIGHT 1444 00:59:53,640 --> 00:59:57,160 LOSS OVER 18 MONTH INTERVENTION 1445 00:59:57,160 --> 00:59:57,480 PERIOD. 1446 00:59:57,480 --> 01:00:01,000 ALL THREE GROUPS REDUCED PAIN BY 1447 01:00:01,000 --> 01:00:02,960 SAME AMOUNT OVER FIRST 6 MONTHS 1448 01:00:02,960 --> 01:00:05,640 AND WASN'T UNTIL 8 TA ENMONTHS 1449 01:00:05,640 --> 01:00:08,560 THAT DIET PLUS EXERCISE GROUPS 1450 01:00:08,560 --> 01:00:11,200 SEPARATED ITSELF FROM OTHER TWO 1451 01:00:11,200 --> 01:00:14,160 GROUPS WITH 51% DECREASE IN 1452 01:00:14,160 --> 01:00:17,280 PAIN. 1453 01:00:17,280 --> 01:00:21,960 YOU CAN REDUCE PAIN BY 50% WITH 1454 01:00:21,960 --> 01:00:23,600 LONG TERM DIETARY WEIGHT LOSS 1455 01:00:23,600 --> 01:00:26,240 AND MODERATE EXERCISE AND 1456 01:00:26,240 --> 01:00:28,240 INFLAMMATORY OUTCOME IO6 WAS 1457 01:00:28,240 --> 01:00:30,600 SIGNIFICANTLY REDUCED IN TWO 1458 01:00:30,600 --> 01:00:33,560 DIET GROUPS 13 AND 14% 1459 01:00:33,560 --> 01:00:35,720 REDUCTIONS COMPARED TO 3% 1460 01:00:35,720 --> 01:00:39,040 INCREASE IN EXERCISE-ONLY 1461 01:00:39,040 --> 01:00:39,720 COMPARISON GROUP. 1462 01:00:39,720 --> 01:00:41,840 KNEE COMPRESSOR FORCES WERE 1463 01:00:41,840 --> 01:00:43,720 REDUCED IN DIET ONLY GROUP 1464 01:00:43,720 --> 01:00:47,240 COMPARED TO EXERCISE GROUP WITH 1465 01:00:47,240 --> 01:00:49,920 DIET AND EXERCISE GROUP BEING 1466 01:00:49,920 --> 01:00:50,400 IN-BETWEEN. 1467 01:00:50,400 --> 01:00:54,000 DIET PLUS EXERCISE REDUCES 1468 01:00:54,000 --> 01:00:56,280 ABNORMAL STRESS DECREASING KNEE 1469 01:00:56,280 --> 01:00:58,640 JOINT LOADS AND [INDISCERNIBLE] 1470 01:00:58,640 --> 01:01:00,640 PHYSIOLOGY BY LOWERING 1471 01:01:00,640 --> 01:01:03,920 INFLAMMATION RESULTING IN LESS 1472 01:01:03,920 --> 01:01:07,800 PAIN AND LESS DISABILITY. 1473 01:01:07,800 --> 01:01:10,240 NOW WE KNOW THAT 10% WEIGHT LOSS 1474 01:01:10,240 --> 01:01:11,960 IS EFFECTIVE IN REDUCING PAIN 1475 01:01:11,960 --> 01:01:14,120 AND NEXT LOGICAL QUESTION WOULD 1476 01:01:14,120 --> 01:01:17,160 BE THERE IS MORE WEIGHT LOSS 1477 01:01:17,160 --> 01:01:17,920 BETTER? 1478 01:01:17,920 --> 01:01:20,200 THIS TABLE SHOWS MEAN DOSE 1479 01:01:20,200 --> 01:01:21,560 RESPONSE TO WEIGHT LOSS FOR PAIN 1480 01:01:21,560 --> 01:01:24,000 AT 18 MONTH FOLLOW UP. 1481 01:01:24,000 --> 01:01:26,480 AS WEIGHT LOSS INCREASED FROM 1482 01:01:26,480 --> 01:01:29,360 GREATER THAN 5% TO GREATER THAN 1483 01:01:29,360 --> 01:01:32,280 10% TO GREATER THAN 20%. 1484 01:01:32,280 --> 01:01:36,160 IT IS A SIGNIFICANT DECREASE IN 1485 01:01:36,160 --> 01:01:37,840 PAIN. 1486 01:01:37,840 --> 01:01:44,760 IN FACT, ACROSS ALL METHODS OF 1487 01:01:44,760 --> 01:01:48,120 WEIGHT LOSS AND WEIGHT LOSS 1488 01:01:48,120 --> 01:01:51,960 INCREASES AND PAIN REDUCTION 1489 01:01:51,960 --> 01:01:52,320 INCREASES. 1490 01:01:52,320 --> 01:01:55,560 BUT WHAT HAPPENS AFTER DIET AND 1491 01:01:55,560 --> 01:01:57,640 EXERCISE INTERVENTION HAS ENDED? 1492 01:01:57,640 --> 01:02:01,120 THERE IS BIOLOGICAL CHANGES THAT 1493 01:02:01,120 --> 01:02:02,800 ATTEMPTS TO MAINTAIN WEIGHT 1494 01:02:02,800 --> 01:02:05,880 LOSS. BODY ACTS IN STARVATION 1495 01:02:05,880 --> 01:02:08,760 MODE INCREASING FEELINGS OF 1496 01:02:08,760 --> 01:02:09,680 HUNGER SUPPRESSES 1497 01:02:09,680 --> 01:02:12,480 [INDISCERNIBLE] AND SLOWS 1498 01:02:12,480 --> 01:02:14,520 METABOLIC RATE AND ATTEMPTS TO 1499 01:02:14,520 --> 01:02:17,280 DEFEND HIGHER BODY WEIGHTS AT 1500 01:02:17,280 --> 01:02:18,520 ALL COSTS. 1501 01:02:18,520 --> 01:02:22,320 THIS FIGURE SHOWS THE CHANGE IN 1502 01:02:22,320 --> 01:02:26,920 WEIGHT AT 3.5 YEARS AFTER THE 1503 01:02:26,920 --> 01:02:28,520 IDEA 18 MONTH INTERVENTION HAD 1504 01:02:28,520 --> 01:02:32,480 ENDED OR FIVE YEARS FROM 1505 01:02:32,480 --> 01:02:33,400 BASELINE. 1506 01:02:33,400 --> 01:02:36,040 EXERCISE ONLY GROUP SHOWN IN THE 1507 01:02:36,040 --> 01:02:38,320 BLACK LINE HAD ZERO WEIGHT 1508 01:02:38,320 --> 01:02:40,080 REGAIN FROM THE END OF THE 1509 01:02:40,080 --> 01:02:41,360 INTERVENTION HAVING A WEIGHT 1510 01:02:41,360 --> 01:02:45,360 LOSS OF 3% FROM BASELINE. 1511 01:02:45,360 --> 01:02:48,520 DIET PLUS EXERCISE GROUP HAD 65% 1512 01:02:48,520 --> 01:02:50,760 WEIGHT REGAIN FROM END OF 1513 01:02:50,760 --> 01:02:51,920 INTERVENTION AND ABLE TO 1514 01:02:51,920 --> 01:02:54,400 MAINTAIN WEIGHT LOSS FROM 4% 1515 01:02:54,400 --> 01:02:56,560 FROM BASELINE AND DIET ONLY 1516 01:02:56,560 --> 01:02:58,600 GROUP HAD 38% WEIGHT REGAIN FROM 1517 01:02:58,600 --> 01:03:00,320 END OF INTERVENTION THAT WAS 1518 01:03:00,320 --> 01:03:02,440 ABLE TO MAINTAIN A WEIGHT LOSS 1519 01:03:02,440 --> 01:03:06,800 FROM 6% FROM BASELINE OR FIVE 1520 01:03:06,800 --> 01:03:08,120 YEARS LATER. 1521 01:03:08,120 --> 01:03:11,320 >>YOU HAVE ABOUT TWO MINUTES. 1522 01:03:11,320 --> 01:03:12,640 THANK YOU. 1523 01:03:12,640 --> 01:03:13,240 >>OKAY. 1524 01:03:13,240 --> 01:03:17,360 ALL THIS RESULTS IN 1.5 UNIT 1525 01:03:17,360 --> 01:03:19,480 REDUCTION IN PAIN AT 5 YEAR 1526 01:03:19,480 --> 01:03:22,880 FOLLOW UP WITH NO SIGNIFICANT 1527 01:03:22,880 --> 01:03:24,560 DIFFERENCE BETWEEN THE GROUPS. 1528 01:03:24,560 --> 01:03:26,560 SO, THEN, MULTIPLE CLINICAL 1529 01:03:26,560 --> 01:03:29,360 TRIALS HAVE BEEN SUCCESSFUL IN 1530 01:03:29,360 --> 01:03:32,200 REDUCING BODY WEIGHT WITH PEOPLE 1531 01:03:32,200 --> 01:03:33,920 WITH KNEE [INDISCERNIBLE] AND 1532 01:03:33,920 --> 01:03:36,080 OBESITY AND WEIGHT REDUCTION LED 1533 01:03:36,080 --> 01:03:37,160 TO SIGNIFICANT REDUCTIONS IN 1534 01:03:37,160 --> 01:03:39,800 PAIN AND IMPROVEMENTS IN 1535 01:03:39,800 --> 01:03:42,320 CLINICAL AND MECHANISTIC 1536 01:03:42,320 --> 01:03:43,480 OUTCOMES. HOWEVER, WEIGHT 1537 01:03:43,480 --> 01:03:45,880 REGAIN CONTINUES TO BE A 1538 01:03:45,880 --> 01:03:48,280 PROBLEM. AN IMPORTANT TOPIC FOR 1539 01:03:48,280 --> 01:03:50,240 FURTHER RESEARCH. 1540 01:03:50,240 --> 01:03:52,520 SO, ASIDE FROM KNEE REPLACEMENT, 1541 01:03:52,520 --> 01:03:56,880 THERE IS NO CURE FOR KNEE 1542 01:03:56,880 --> 01:03:57,240 OSTEOARTHRITIS. 1543 01:03:57,240 --> 01:04:00,040 THEN IS PREVENTION BETTER THAN 1544 01:04:00,040 --> 01:04:00,640 TREATMENT? 1545 01:04:00,640 --> 01:04:05,000 SEVERAL GROUPS ADDRESSING NEO-A 1546 01:04:05,000 --> 01:04:08,760 PREVENTION AS WE SPEAK AND 1547 01:04:08,760 --> 01:04:09,760 OSTEOARTHRITIS PREVENTION STUDY 1548 01:04:09,760 --> 01:04:11,760 WILL BEGIN RECRUITING 1549 01:04:11,760 --> 01:04:13,040 PARTICIPANTS LATER IN THE FALL. 1550 01:04:13,040 --> 01:04:16,840 WE WERE RANDOMIZED 1 THOUSAND 1551 01:04:16,840 --> 01:04:19,760 230 PEOPLE AT RISK FOR KNEE 1552 01:04:19,760 --> 01:04:21,640 OSTEOARTHRITIS IN ONE OF 2 1553 01:04:21,640 --> 01:04:23,880 GROUPS DIET PLUS EXERCISE OR 1554 01:04:23,880 --> 01:04:25,160 CONTROL AND STUDY POPULATION 1555 01:04:25,160 --> 01:04:27,000 WOULD BE ALL FEMALE AGE GREATER 1556 01:04:27,000 --> 01:04:29,360 THAN OR EQUAL TO 50 YEARS AND 1557 01:04:29,360 --> 01:04:31,760 BMI GREATER THAN OR EQUAL TO 1558 01:04:31,760 --> 01:04:36,080 THRT WITH NO X-RAY OR MRIOA AND 1559 01:04:36,080 --> 01:04:39,160 ON ONE OR BOTH KNEES AND NO 1560 01:04:39,160 --> 01:04:42,360 INFREQUENT KNEE PAIN. 1561 01:04:42,360 --> 01:04:44,960 THANK YOU. 1562 01:04:44,960 --> 01:04:48,800 >>THANKS SO MUCH, DR. MESSIER. 1563 01:04:48,800 --> 01:04:52,640 ALEX, ARE WE READY FOR DR. 1564 01:04:52,640 --> 01:04:54,320 RAGHAVAN TO TAKE OVER? 1565 01:04:54,320 --> 01:05:01,520 >>YES, DR. RAGHAVAN. 1566 01:05:01,520 --> 01:05:12,040 >>WE NEED YOU TO DO THE FULL 1567 01:05:13,080 --> 01:05:16,520 SCREEN, PLEASE, OF YOUR SLIDE. 1568 01:05:16,520 --> 01:05:16,800 SLIDESHOW. 1569 01:05:16,800 --> 01:05:18,920 >>UNMUTE. CAN YOU HEAR ME NOW? 1570 01:05:18,920 --> 01:05:21,360 >>YES, WE CAN HEAR YOU. 1571 01:05:21,360 --> 01:05:23,520 >>TERRIFIC. 1572 01:05:23,520 --> 01:05:25,840 >>YES IF YOU CAN GO AHEAD AND 1573 01:05:25,840 --> 01:05:30,480 DO THE SLIDESHOW, THAT WOULD BE 1574 01:05:30,480 --> 01:05:40,680 WONDERFUL. 1575 01:05:45,440 --> 01:05:46,760 >>CAN YOU SEE? 1576 01:05:46,760 --> 01:05:48,560 >>THAT WORKS. THANK YOU. 1577 01:05:48,560 --> 01:05:49,840 >>THANK YOU VERY MUCH FOR 1578 01:05:49,840 --> 01:05:51,040 HAVING ME. 1579 01:05:51,040 --> 01:05:53,160 IT HAS BEEN A FANTASTIC 1580 01:05:53,160 --> 01:05:55,120 CONFERENCE. BEFORE I BEGIN, I 1581 01:05:55,120 --> 01:05:57,880 NEED TO MAKE SOME DISCLOSURES 1582 01:05:57,880 --> 01:06:00,640 AND WILL DISCUSS THE OFF LABEL 1583 01:06:00,640 --> 01:06:02,640 USE OF ENZYME [INDISCERNIBLE] 1584 01:06:02,640 --> 01:06:05,080 FOR MUSCLE STIFFNESS AND PAIN. 1585 01:06:05,080 --> 01:06:07,600 SO, AS WE HAVE HEARD OVER THE 1586 01:06:07,600 --> 01:06:11,200 LAST DAY AND A FEW HOURS, 1587 01:06:11,200 --> 01:06:13,600 MUSCLES ARE ALSO INTEGRAL TO 1588 01:06:13,600 --> 01:06:16,040 JOINT HEALTH. WE HAVE OVER 600 1589 01:06:16,040 --> 01:06:20,640 MUSCLES IN OUR BODY. 1590 01:06:20,640 --> 01:06:23,160 IN FACT, IT HAS BEEN SHOWN THAT 1591 01:06:23,160 --> 01:06:25,400 A LARGE PROPORTION OF JOINT PAIN 1592 01:06:25,400 --> 01:06:26,600 IS MUSCLE RELATED. 1593 01:06:26,600 --> 01:06:31,040 IN FACT, IT IS CALLED MYOFASH YO 1594 01:06:31,040 --> 01:06:34,600 PAIN AND 100% OF PATIENTS WITH 1595 01:06:34,600 --> 01:06:37,840 NECK PAIN HAVE BEEN SHOWN TO 1596 01:06:37,840 --> 01:06:41,480 HAVE MIOFASHIAL PAIN. WHAT IS 1597 01:06:41,480 --> 01:06:43,080 MIOFASHIAL PAIN THAT WAS DEFINED 1598 01:06:43,080 --> 01:06:47,600 IN 1950S AS LOCALIZED TENSION 1599 01:06:47,600 --> 01:06:53,360 AREA IN THE SKELETAL MUSCLE AND 1600 01:06:53,360 --> 01:07:03,840 FASCIA -- ELICITED IN THE 1601 01:07:16,040 --> 01:07:17,120 TRIGGER POINT. THIS IS 1602 01:07:17,120 --> 01:07:22,720 DESCRIBED IN THE 1990S BY HONG 1603 01:07:22,720 --> 01:07:24,680 ET AL WHERE THEY PUT A NEEDLE 1604 01:07:24,680 --> 01:07:27,640 INTO THE MUSCLE TENSION AREA AND 1605 01:07:27,640 --> 01:07:30,800 THEY DETECTED EMG ACTIVITY. 1606 01:07:30,800 --> 01:07:33,560 AND THEY SURMISED THAT A LOCAL 1607 01:07:33,560 --> 01:07:40,040 TWITCH RESPONSE NEEDS AN IN TACT 1608 01:07:40,040 --> 01:07:45,760 CENTKREN 1609 01:07:45,760 --> 01:07:46,640 KR 1610 01:07:46,640 --> 01:07:47,840 CENTRAL INNERVATION AND NERVE 1611 01:07:47,840 --> 01:07:51,160 BLOCK TO AMELIORATE LOCAL TWITCH 1612 01:07:51,160 --> 01:07:52,920 RESPONSE AND REDUCE PAIN AND 1613 01:07:52,920 --> 01:07:54,960 THEY DID A STUDY WHERE THEY GAVE 1614 01:07:54,960 --> 01:07:58,280 DRY NEEDLING VERSUS LIEDO CANE 1615 01:07:58,280 --> 01:08:00,160 INJECTION AND WOULD EXPECT THAT 1616 01:08:00,160 --> 01:08:02,120 PERHAPS LIEDO CANE INJECTION 1617 01:08:02,120 --> 01:08:04,680 BECAUSE IT AMELIORATES LOCAL 1618 01:08:04,680 --> 01:08:06,920 TWITCH RESPONSE DUE TO CENTRAL 1619 01:08:06,920 --> 01:08:08,520 INNERVATION WOULD GET RID OF THE 1620 01:08:08,520 --> 01:08:13,360 PAIN. TURNS OUT THAT THE DRY 1621 01:08:13,360 --> 01:08:15,040 NEEDLING ALSO [INDISCERNIBLE] 1622 01:08:15,040 --> 01:08:25,560 THE PAIN LIEDZO CANE REDUCED 1623 01:08:27,720 --> 01:08:29,320 SORENESS FROM THE PROCEDURE -- 1624 01:08:29,320 --> 01:08:31,360 THIS CREATES A DEGREE OF 1625 01:08:31,360 --> 01:08:32,640 CONFUSION BECAUSE IT IS NOT 1626 01:08:32,640 --> 01:08:36,440 CLEAR WHETHER IT IS JUST THE 1627 01:08:36,440 --> 01:08:37,600 NERVOUS SYSTEM OR NERVE 1628 01:08:37,600 --> 01:08:39,720 INNOVATION THAT IS LEADING TO 1629 01:08:39,720 --> 01:08:41,200 THIS TWITCH RESPONSE OR WHETHER 1630 01:08:41,200 --> 01:08:43,000 IT IS SOMETHING ELSE THAT IS 1631 01:08:43,000 --> 01:08:45,000 LOCAL IN THE MUSCLE. 1632 01:08:45,000 --> 01:08:48,760 IN FACT, THERE ARE SEVERAL 1633 01:08:48,760 --> 01:08:51,360 COMMON TREATMENTS USED BUT ALL 1634 01:08:51,360 --> 01:08:54,720 TREATMENTS HAVE BEEN FOUND TO BE 1635 01:08:54,720 --> 01:08:58,800 MODERATELY EFFECTIVE OR IN ONE 1636 01:08:58,800 --> 01:09:05,000 STUDY IN 201054% OF PHYSICIANS 1637 01:09:05,000 --> 01:09:09,360 CHARACTERIZED INAVAILABLE OPTION 1638 01:09:09,360 --> 01:09:11,760 TREATMENTS AS INSUFFICIENT AND 1639 01:09:11,760 --> 01:09:13,960 INJECTION THERAPIES IS NOT CLEAR 1640 01:09:13,960 --> 01:09:16,200 WHAT IS BEST TREATMENT AND IN 1641 01:09:16,200 --> 01:09:20,120 FACT IN 20201 REVIEW ARTICLE 1642 01:09:20,120 --> 01:09:21,280 SUGGESTED THAT OVERALL THERE WAS 1643 01:09:21,280 --> 01:09:25,360 NO CONSENSUS IN ETIOLOGY AND 1644 01:09:25,360 --> 01:09:27,680 PATHOGENESIS OF MYOFASCIAL PAIN 1645 01:09:27,680 --> 01:09:30,600 SYNDROME AND NO UNIFIED 1646 01:09:30,600 --> 01:09:31,600 DIAGNOSIS OF TREATMENT STANDARD 1647 01:09:31,600 --> 01:09:38,360 AND IN 1997, GER WIN WROTE THERE 1648 01:09:38,360 --> 01:09:40,720 WAS POOR RATE OF RELIABLE THE OF 1649 01:09:40,720 --> 01:09:42,440 THE LOCAL TWITCH RESPONSE. 1650 01:09:42,440 --> 01:09:44,880 WHAT ARE THE KEY GAPS THAT ARE 1651 01:09:44,880 --> 01:09:48,160 WHAT IS THE TRIGGER POINT MADE 1652 01:09:48,160 --> 01:09:50,840 OF? BEGS US TO TAKE CLOSER LOOK 1653 01:09:50,840 --> 01:09:56,040 AT MUSCLE ARCHITECTURE. 1654 01:09:56,040 --> 01:09:59,280 WE HEARD YESTERDAY THAT MUSCLE 1655 01:09:59,280 --> 01:10:03,080 IS MADE OF MUSCLE FIBERS AND 1656 01:10:03,080 --> 01:10:04,400 NETWORK CONSISTING OF EXTRA 1657 01:10:04,400 --> 01:10:07,560 CELLULAR MATRIX AS WELL IN EXTRA 1658 01:10:07,560 --> 01:10:10,840 CELLULAR MATRIX THAT NERVE 1659 01:10:10,840 --> 01:10:14,600 FIBERS AND VASCULAR VASCULATURE 1660 01:10:14,600 --> 01:10:16,560 ENTERS MUSCLE. 1661 01:10:16,560 --> 01:10:19,000 IT HAS BEEN FOUND THAT EXTRA 1662 01:10:19,000 --> 01:10:23,720 CELLULAR MATRIX IS COMPOSED OF 1663 01:10:23,720 --> 01:10:27,240 SUGAR MOLECULE AND IN SLIDE YOU 1664 01:10:27,240 --> 01:10:31,600 SEE QUADRICEPS MUSCLE SHOWS 1665 01:10:31,600 --> 01:10:33,520 BINDING PROTEIN THAT STAINS 1666 01:10:33,520 --> 01:10:35,640 BROWN. YOU CAN SEE IT IS AROUND 1667 01:10:35,640 --> 01:10:38,240 THE MUSCLE FIBER RIGHT WHERE YOU 1668 01:10:38,240 --> 01:10:43,600 EXPECT THE ENDOMYOSIN WITH 1669 01:10:43,600 --> 01:10:45,960 COLLAGEN AND IN PERIMYSIUM 1670 01:10:45,960 --> 01:10:48,200 SURROUNDING BUNDLES OF MUSCLE 1671 01:10:48,200 --> 01:10:49,360 FIBERS WASHED OUT BY 1672 01:10:49,360 --> 01:10:52,800 [INDISCERNIBLE] AS YOU SEE IN 1673 01:10:52,800 --> 01:10:55,000 THE LOWER PANEL. 1674 01:10:55,000 --> 01:10:59,000 TURNS OUT IT IS NOT EXTRA 1675 01:10:59,000 --> 01:11:00,240 CELLULAR MATRIX BUT ALSO STRETCH 1676 01:11:00,240 --> 01:11:02,040 RECEPTORS IN THE MUSCLE THAT ARE 1677 01:11:02,040 --> 01:11:05,360 LOCATED ACTUALLY IN PERIMYSIUM 1678 01:11:05,360 --> 01:11:07,480 THAT ARE RICH IN HIGH LURE ONIC 1679 01:11:07,480 --> 01:11:09,560 ACID THAT IS BROWN STAINING AND 1680 01:11:09,560 --> 01:11:12,240 STRUCTURES AND MUSCLE SPINDLE 1681 01:11:12,240 --> 01:11:17,120 THAT IS STRETCH RECEPTOR AND 1682 01:11:17,120 --> 01:11:19,080 PERINEURAL SPACE IS ALSO RICH IN 1683 01:11:19,080 --> 01:11:21,800 HIGH LURE ONIC ACID AND 1684 01:11:21,800 --> 01:11:24,880 DISRUPTION IN THRESHOLD OF THE 1685 01:11:24,880 --> 01:11:29,080 GRADIENT BETWEEN HIGH LURE ONIC 1686 01:11:29,080 --> 01:11:31,640 ACID INSIDE AND OUTSIDE MIGHT 1687 01:11:31,640 --> 01:11:34,160 DISRUPT SENSITIVITY OF MUSCLE 1688 01:11:34,160 --> 01:11:36,360 SPINDLE AND MIGHT LEAD TO 1689 01:11:36,360 --> 01:11:40,080 DISRUPTION IN NERVE ACTIVATION. 1690 01:11:40,080 --> 01:11:43,200 SO, [INDISCERNIBLE] AS I 1691 01:11:43,200 --> 01:11:48,280 MENTIONED PREVIOUSLY IS A SUGAR 1692 01:11:48,280 --> 01:11:50,520 MOLECULE AND CONCENTRATIONS ACT 1693 01:11:50,520 --> 01:11:55,360 AS -- TWO MUSCLE FIBERS WITH 1694 01:11:55,360 --> 01:11:58,800 THIN LAYER IN BETWEEN AND WHEN 1695 01:11:58,800 --> 01:12:01,640 MUSCLE CONTRACTS FORCE IS 1696 01:12:01,640 --> 01:12:03,120 TRANSMITTED ACROSS MULTIPLE 1697 01:12:03,120 --> 01:12:06,000 MUSCLE FIBERS THAT SLIDE AGAINST 1698 01:12:06,000 --> 01:12:08,960 EACH OTHER FOR TRANSMISSION TO 1699 01:12:08,960 --> 01:12:09,880 [INDISCERNIBLE]. 1700 01:12:09,880 --> 01:12:11,960 HOWEVER, WHEN TOO MUCH HIGH LURE 1701 01:12:11,960 --> 01:12:15,560 ONIC ACID IT AGGREGATES LEADING 1702 01:12:15,560 --> 01:12:18,040 TO INCREASED VISCOSITY DECREASE 1703 01:12:18,040 --> 01:12:19,560 IN LUBRICATION AND TISSUE 1704 01:12:19,560 --> 01:12:21,280 SLIDING AND CONCENTRATION OF 1705 01:12:21,280 --> 01:12:25,240 HIGH LURE ONIC ACID INCREASES 1706 01:12:25,240 --> 01:12:26,800 VISCOSITY OF EXTRA CELLULAR 1707 01:12:26,800 --> 01:12:28,880 MATRIX EXPONENTIALLY INCREASES 1708 01:12:28,880 --> 01:12:30,000 THAT CAN FORM ACTUALLY 1709 01:12:30,000 --> 01:12:34,000 STRUCTURES THAT LITERALLY BIND 1710 01:12:34,000 --> 01:12:35,200 AREA TOGETHER. 1711 01:12:35,200 --> 01:12:38,840 NOW, IF YOU LOOK AT SAME MODEL 1712 01:12:38,840 --> 01:12:40,280 WITH LAYER OF [INDISCERNIBLE] 1713 01:12:40,280 --> 01:12:41,720 YOU FIND THAT YOU KNOW THERE IS 1714 01:12:41,720 --> 01:12:43,360 IF NOT MUCH MOVEMENT OR SLIDING 1715 01:12:43,360 --> 01:12:46,280 OF THE MUSCLES THAT MUSCLES ARE 1716 01:12:46,280 --> 01:12:48,800 STUCK AND MAY FEEL STIFF AND 1717 01:12:48,800 --> 01:12:50,600 PRODUCE REDISTANCE TO MOVEMENT 1718 01:12:50,600 --> 01:12:52,920 AND THAT COULD YOU KNOW IF YOU 1719 01:12:52,920 --> 01:12:55,560 TRIED TO STRETCH A STUCK MUSCLE 1720 01:12:55,560 --> 01:12:58,560 THAT MAY ACTIVATE STRETCH REFLEX 1721 01:12:58,560 --> 01:13:03,400 CAUSING A TWITCH. WE HAD 1722 01:13:03,400 --> 01:13:04,800 PROPOSED HIGH LURE OWN 1723 01:13:04,800 --> 01:13:06,480 HYPOTHESIS OF MUSCLE STIFFNESS 1724 01:13:06,480 --> 01:13:10,120 WHERE IN PATIENTS OF IMMOBILITY 1725 01:13:10,120 --> 01:13:13,400 AND PARESIS DUE TO NEUROLOGICAL 1726 01:13:13,400 --> 01:13:17,440 CONDITION OF STROKE DECREASED 1727 01:13:17,440 --> 01:13:19,960 DEGRADATION OF HA AND SIMILARLY 1728 01:13:19,960 --> 01:13:21,360 OVERUSE OF EXCESSIVE 1729 01:13:21,360 --> 01:13:23,080 INFLAMMATION CAN PRODUCE HA AND 1730 01:13:23,080 --> 01:13:25,120 LEADING TO INCREASED 1731 01:13:25,120 --> 01:13:25,480 ACCUMULATION. 1732 01:13:25,480 --> 01:13:28,000 WE SUMMARIZED THIS IN A TEXTBOOK 1733 01:13:28,000 --> 01:13:30,160 JUST PUBLISHED RECENTLY AND NOW 1734 01:13:30,160 --> 01:13:32,280 CAN USE IMAGING TO ACTUALLY 1735 01:13:32,280 --> 01:13:34,960 IMAGE IN VIVO THIS ACCUMULATION. 1736 01:13:34,960 --> 01:13:37,840 YOU SEE HERE IN PATIENTS WITH 1737 01:13:37,840 --> 01:13:40,080 SPAS TICK PARESIS DUE TO STROKE 1738 01:13:40,080 --> 01:13:42,120 COMPARED TO CONTROL IN TOP PANEL 1739 01:13:42,120 --> 01:13:44,360 AND MIDDLE PANEL YOU SEE LOTS OF 1740 01:13:44,360 --> 01:13:47,600 RED AND MORE RED SIGNALS MORE 1741 01:13:47,600 --> 01:13:49,680 HIGH LURE ONIC ACID ACCUMULATION 1742 01:13:49,680 --> 01:13:53,280 AND SEE MUSCLE LOOKS KIND OF 1743 01:13:53,280 --> 01:13:55,480 STUCK TOGETHER WHERE SHAPE IS 1744 01:13:55,480 --> 01:13:56,880 TRIANGULAR RATHER THAN CIRCULAR 1745 01:13:56,880 --> 01:14:00,280 AND BOTTOM PANEL YOU SEE THE 1746 01:14:00,280 --> 01:14:02,920 SAME PATIENT AND SAME MUSCLES 1747 01:14:02,920 --> 01:14:05,680 BUT AFTER TREATMENT WITH ENZYME 1748 01:14:05,680 --> 01:14:08,920 HIGH LURE ONO DAZE YOU SEE LEFT 1749 01:14:08,920 --> 01:14:10,520 HIGH LURE OWNIN AND CHANGES IN 1750 01:14:10,520 --> 01:14:13,360 SHAPE OF THE MUSCLE. 1751 01:14:13,360 --> 01:14:16,880 NOW, HERE IS A EXAMPLE OF SAME 1752 01:14:16,880 --> 01:14:20,840 IMAGING TECHNIQUE BEING USED 1753 01:14:20,840 --> 01:14:23,400 PATIENTS WITH OVERUSE AND TENNIS 1754 01:14:23,400 --> 01:14:25,840 ELBOW AND IF YOU LOOK AT TOP 1755 01:14:25,840 --> 01:14:30,120 PANEL YOU SEE THERE IS HIGH LURE 1756 01:14:30,120 --> 01:14:37,320 OWNIAN ACCUMULATION IN EPIMICE 1757 01:14:37,320 --> 01:14:41,320 YO REGION ON BOTH SIDES AND POST 1758 01:14:41,320 --> 01:14:44,160 PANEL YOU SEE HIGHAL YOU ARE OWN 1759 01:14:44,160 --> 01:14:49,360 AN SEEMS TO DECREASE AND AREAS 1760 01:14:49,360 --> 01:15:00,160 TREATED WITH MANUALWITH MANUAL 1761 01:15:00,160 --> 01:15:02,800 ANOTHER EXAMPLE OF THE SAME T1 1762 01:15:02,800 --> 01:15:05,680 ROW IMAGING TECHNIQUE WHERE YOU 1763 01:15:05,680 --> 01:15:08,280 CANNIM AN HYALURONAN 1764 01:15:08,280 --> 01:15:12,800 ACCUMULATION IN PATIENTS WITH 1765 01:15:12,800 --> 01:15:14,560 MYOFASHIAL SHOULDER PAIN AND 1766 01:15:14,560 --> 01:15:18,600 EFFECTED SIDE IS LOTS OF RED 1767 01:15:18,600 --> 01:15:20,720 SIGNALING HYALURONAN 1768 01:15:20,720 --> 01:15:23,880 ACCUMULATION IN PECTORALIS MAJOR 1769 01:15:23,880 --> 01:15:25,280 MINOR PARTICULARLY AT INTERFACE 1770 01:15:25,280 --> 01:15:28,200 OF TWO MUSCLES AND HARD TO REACH 1771 01:15:28,200 --> 01:15:38,600 THAT BIOMANUAL THERAPY. 1772 01:15:39,560 --> 01:15:41,120 JUST VERY BRIEFLY WHAT THIS IS 1773 01:15:41,120 --> 01:15:44,760 SHOWING YOU IS THAT YOU CAN LOOK 1774 01:15:44,760 --> 01:15:50,920 AT THE FASCIA INTERFACE FWEN 1775 01:15:50,920 --> 01:15:52,000 PECTORALIS MAJOR AND MINOR SHOWN 1776 01:15:52,000 --> 01:15:54,840 HERE WITH COLORS RED AND BLUE 1777 01:15:54,840 --> 01:15:56,560 AND LOWER GRAPH, HERE THE 1778 01:15:56,560 --> 01:15:58,840 PATIENT IS MOVING AND YOU SEE ON 1779 01:15:58,840 --> 01:16:00,880 UNAFFECTED SIDE THAT THE RED AND 1780 01:16:00,880 --> 01:16:04,240 BLUE MOVE SEPARATELY AND 1781 01:16:04,240 --> 01:16:06,360 ACTUALLY DURING EXTERNAL AND 1782 01:16:06,360 --> 01:16:09,800 INTERNAL ROTATION AND PECTORALIS 1783 01:16:09,800 --> 01:16:11,480 MUSCLE DOESN'T MOVE AND YOU SEE 1784 01:16:11,480 --> 01:16:13,240 RED LINE CHANGING AND BLUE LINE 1785 01:16:13,240 --> 01:16:14,520 IS STATIC. 1786 01:16:14,520 --> 01:16:17,360 WHEN YOU LOOK AT SHEER BETWEEN 1787 01:16:17,360 --> 01:16:20,560 TWO MUSCLES YOU SEE A NICE BLACK 1788 01:16:20,560 --> 01:16:23,000 LINE WHEREAS ON THE EFFECTED 1789 01:16:23,000 --> 01:16:26,960 SIDE YOU SEE THAT BOTH MUSCLES 1790 01:16:26,960 --> 01:16:28,160 MOVE TOGETHER. 1791 01:16:28,160 --> 01:16:31,640 WHICH ACTUALLY DISRUPTS THE 1792 01:16:31,640 --> 01:16:34,240 MOVEMENT OF THE TWO MUSCLES 1793 01:16:34,240 --> 01:16:36,320 AGAINST EACH OTHER AS IT SHOULD 1794 01:16:36,320 --> 01:16:39,280 BE FUNCTIONALLY. 1795 01:16:39,280 --> 01:16:41,280 SO, WHAT IS THE CONSEQUENCE? 1796 01:16:41,280 --> 01:16:43,640 HOW CAN WE REDUCE MUSCLES FROM 1797 01:16:43,640 --> 01:16:46,320 BEING STUCK TOGETHER LIKE THIS? 1798 01:16:46,320 --> 01:16:50,800 TURNS OUT THAT ENZYME HIGHAL YOU 1799 01:16:50,800 --> 01:16:53,120 ARE ON AN DAYS HAS BEEN 1800 01:16:53,120 --> 01:16:54,560 AVAILABLE FOR A LONG TIME AND 1801 01:16:54,560 --> 01:16:58,800 USED TO INCREASE AND IMPROVE 1802 01:16:58,800 --> 01:17:03,640 DRUG LIVERY OF AGENTS HIGHAL YOU 1803 01:17:03,640 --> 01:17:07,160 ARE ONIDAYS WAS IMPROVED IN 1804 01:17:07,160 --> 01:17:07,640 2005. 1805 01:17:07,640 --> 01:17:11,120 THINKING IT WAS SOMETHING THAT 1806 01:17:11,120 --> 01:17:21,680 COULD DECREASE -- DISRUPT THIS 1807 01:17:22,760 --> 01:17:24,040 CASCADE OF DISABILITY WE OFTEN 1808 01:17:24,040 --> 01:17:25,120 SEE IN PATIENTS. 1809 01:17:25,120 --> 01:17:29,280 >>YOU HAVE A COUPLE OF MINUTES. 1810 01:17:29,280 --> 01:17:31,720 SO, IN K SERIES THAT WE FIRST 1811 01:17:31,720 --> 01:17:35,760 DID, WE SAW DRAMATIC REDUCTION 1812 01:17:35,760 --> 01:17:38,640 IN DEGREE OF MUSCLE STIFFNESS 1813 01:17:38,640 --> 01:17:40,800 ACROSS MULTIPLE JOINTS BETWEEN 1814 01:17:40,800 --> 01:17:44,240 T0 AND T1. THIS IS WHERE 1815 01:17:44,240 --> 01:17:45,400 INJECTIONS WERE GIVEN. 1816 01:17:45,400 --> 01:17:48,680 AND WE SAW IMPROVEMENTS IN 1817 01:17:48,680 --> 01:17:50,560 PAIN-FREE MOVEMENT ACROSS 1818 01:17:50,560 --> 01:17:51,520 MULTIPLE JOINTS. 1819 01:17:51,520 --> 01:17:53,840 NOW, MOST RECENTLY IN A 1820 01:17:53,840 --> 01:17:57,280 CLINICAL TRIAL THAT IS STILL 1821 01:17:57,280 --> 01:18:00,240 ONGOING, WE TOOK A SNEAK PEAK 1822 01:18:00,240 --> 01:18:01,360 BECAUSE PATIENTS ARE GETTING 1823 01:18:01,360 --> 01:18:04,960 BOTH PLACEBO AND THE TREATMENT 1824 01:18:04,960 --> 01:18:06,520 BETWEEN -- IN THE STUDY. 1825 01:18:06,520 --> 01:18:10,400 WE SEE THAT WHEN WE LOOK AT THE 1826 01:18:10,400 --> 01:18:13,640 HYPERREFLEXIA USING A TENDON 1827 01:18:13,640 --> 01:18:14,920 TAP, YOU SEE THAT IN SUBJECTS 1828 01:18:14,920 --> 01:18:21,360 WITH UNILATERAL HYPERREFLEX AREA 1829 01:18:21,360 --> 01:18:23,560 EFFECTED BASELINE THERE IS GREAT 1830 01:18:23,560 --> 01:18:26,920 DMG ACTIVITY AND AT END OF THE 1831 01:18:26,920 --> 01:18:29,080 TRIAL AFTER THERE IS BOTH DRUG 1832 01:18:29,080 --> 01:18:31,840 AND PLACEBO YOU SEE THERE IS AN 1833 01:18:31,840 --> 01:18:36,680 EFFECT ON EMG AND THEY DON'T 1834 01:18:36,680 --> 01:18:38,760 SHOW HYPERREFLEXIA ANYMORE. 1835 01:18:38,760 --> 01:18:42,720 SO, WHAT WE BELIEVE WE HAVE 1836 01:18:42,720 --> 01:18:49,920 GOTTEN TO IS THAT HYALURONIDASE 1837 01:18:49,920 --> 01:18:52,160 ACTS ON STRETCH REFLEX MECHANISM 1838 01:18:52,160 --> 01:18:55,000 AND ACTUALLY RELAXES THE REGION 1839 01:18:55,000 --> 01:18:57,120 AROUND THE MUSCLE SPINDLE AND 1840 01:18:57,120 --> 01:18:59,880 THEREFORE IT EFFECTS THE 1841 01:18:59,880 --> 01:19:01,320 AFTERERIENT ARM OF THE STRETCH 1842 01:19:01,320 --> 01:19:04,960 REFLEX SO MUSCLE SPINDLE IS LESS 1843 01:19:04,960 --> 01:19:06,520 SENSITIVE TO STRETCH AND THE 1844 01:19:06,520 --> 01:19:08,400 NERVOUS SYSTEM DOESN'T HAVE TO 1845 01:19:08,400 --> 01:19:10,120 BE AS RESPONSIVE TO THE STRETCH. 1846 01:19:10,120 --> 01:19:13,360 IT TURNS OUT IN POST STROKE 1847 01:19:13,360 --> 01:19:15,320 SHOULDER PAIN AS WELL THAT LARGE 1848 01:19:15,320 --> 01:19:19,400 PORTIONS OF THE PAIN IS 1849 01:19:19,400 --> 01:19:19,800 MUSCULOSKELETAL. 1850 01:19:19,800 --> 01:19:22,880 IN OUR STUDIES IN PATIENTS WITH 1851 01:19:22,880 --> 01:19:25,080 STROKE WE HAD FOUND THAT NOT 1852 01:19:25,080 --> 01:19:28,040 ONLY DOES PAIN-FREE MOVEMENT 1853 01:19:28,040 --> 01:19:31,200 INCREASE BUT PAIN PRESSURE 1854 01:19:31,200 --> 01:19:32,800 THRESHOLDS ALSO DECREASE. 1855 01:19:32,800 --> 01:19:35,080 CHANGE IN PAIN PRESSURE 1856 01:19:35,080 --> 01:19:36,720 THRESHOLDS IS DIFFERENT ACROSS 1857 01:19:36,720 --> 01:19:37,640 DIFFERENT MUSCLES AND PERHAPS 1858 01:19:37,640 --> 01:19:40,800 THEY HAVE DIFFERENT DEGREES OF 1859 01:19:40,800 --> 01:19:41,720 DIFFERENT DOSES OF THE 1860 01:19:41,720 --> 01:19:43,280 TREATMENT. YOU CAN SEE OVERALL 1861 01:19:43,280 --> 01:19:47,600 ACROSS ALL MUSCLES THERE IS A 1862 01:19:47,600 --> 01:19:51,120 REDUCTION IN PAIN PRESSURE 1863 01:19:51,120 --> 01:19:52,720 THRESHOLDS AND IN ANOTHER STUDY 1864 01:19:52,720 --> 01:19:55,640 WAS FOUND THAT WHEN THEY 1865 01:19:55,640 --> 01:20:00,320 COMPARED HYALURONIDASE AGAINST 1866 01:20:00,320 --> 01:20:02,760 LIDOCAINE THEY FOUND THAT 1867 01:20:02,760 --> 01:20:04,200 HYALURONIDASE AND LIDOCAINE HAD 1868 01:20:04,200 --> 01:20:06,560 A RESPONSE AND EFFECT AND 1869 01:20:06,560 --> 01:20:08,240 LIDOCAINE HAD SHORT-TERM EFFECTS 1870 01:20:08,240 --> 01:20:12,120 AND HYALURONIDASE HAD LONG TERM 1871 01:20:12,120 --> 01:20:16,600 EFFECT IN 2 TO 4 WEEKS. 1872 01:20:16,600 --> 01:20:18,040 SUMMARIZING -- EXTRA CELLULAR 1873 01:20:18,040 --> 01:20:20,000 MATRIX OF THE MUSCLE MIGHT BE 1874 01:20:20,000 --> 01:20:21,640 CHIEF [INDISCERNIBLE] OF TRIGGER 1875 01:20:21,640 --> 01:20:25,640 POINT IN MYOFASCIAL PAIN BUT 1876 01:20:25,640 --> 01:20:28,680 COULD MODULATE STIFF NNS PAIN 1877 01:20:28,680 --> 01:20:31,680 AND NEURAL REFLEX INDUCED MUSCLE 1878 01:20:31,680 --> 01:20:35,280 ACTIVITY WHICH WE SEE IN 1879 01:20:35,280 --> 01:20:37,000 NEUROLOGICAL PATIENTS AND HIGH 1880 01:20:37,000 --> 01:20:41,320 ALLURE ON AN -- AND MAY LEAD TO 1881 01:20:41,320 --> 01:20:43,640 PAIN RELIEF IN MYOFASCIAL PAIN 1882 01:20:43,640 --> 01:20:45,160 BUT RESULTS HAVE TO BE CONFIRMED 1883 01:20:45,160 --> 01:20:48,040 IN RANDOMIZED CONTROLLED TRIALS 1884 01:20:48,040 --> 01:20:49,720 AND WOULD LIKE TO END BY 1885 01:20:49,720 --> 01:20:52,480 ACKNOWLEDGING ALL CONTRIBUTORS 1886 01:20:52,480 --> 01:20:54,240 AND COLLABORATORS AND FUNDING 1887 01:20:54,240 --> 01:20:55,520 SOURCES THAT MADE THIS WORK 1888 01:20:55,520 --> 01:20:57,360 POSSIBLE. THANK YOU. 1889 01:20:57,360 --> 01:21:01,360 >>THANK YOU DR. RAGHAVAN AND 1890 01:21:01,360 --> 01:21:04,400 APPRECIATE THIS TALK AND 1891 01:21:04,400 --> 01:21:05,040 CONCLUDES OUR SPEAKER SECTION 1892 01:21:05,040 --> 01:21:06,880 FOR SESSION 4 AND WOULD NEXT 1893 01:21:06,880 --> 01:21:08,480 LIKE TO TURN OVER OUR ATTENTION 1894 01:21:08,480 --> 01:21:13,960 TO THE PANELISTS SO DR. GUNNAR 1895 01:21:13,960 --> 01:21:16,720 BROLINSON COULD INTRODUCE 1896 01:21:16,720 --> 01:21:19,640 YOURSELF LEADING OFF THIS PANEL 1897 01:21:19,640 --> 01:21:21,240 INTRODUCTION SECTION? THANK 1898 01:21:21,240 --> 01:21:21,440 YOU. 1899 01:21:21,440 --> 01:21:25,440 >>HI, THERE I'M GUNNAR AND VICE 1900 01:21:25,440 --> 01:21:27,120 PROVOST OF RESEARCH AND 1901 01:21:27,120 --> 01:21:28,520 PROFESSOR OF FAMILIES 1902 01:21:28,520 --> 01:21:30,200 [INDISCERNIBLE] AT VCOM. 1903 01:21:30,200 --> 01:21:33,640 WE HAVE FOUR CAMPUSES. 1904 01:21:33,640 --> 01:21:37,360 AND DR. KOROSHETZ WILL BE HAPPY 1905 01:21:37,360 --> 01:21:39,160 TO KNOW I WILL START MY VIDEO 1906 01:21:39,160 --> 01:21:40,680 AND THERE IT GOES, HOPEFULLY. 1907 01:21:40,680 --> 01:21:42,520 YOU WILL BE HAPPY TO KNOW WE ARE 1908 01:21:42,520 --> 01:21:45,120 A RURALLY DISTRIBUTED MEDICAL 1909 01:21:45,120 --> 01:21:49,280 EDUCATION SYSTEM AND RECRUIT AND 1910 01:21:49,280 --> 01:21:50,480 RETAIN STUDENTS FROM RURAL AREAS 1911 01:21:50,480 --> 01:21:54,480 AND ARE TRYING TO REALLY BUILD 1912 01:21:54,480 --> 01:21:56,760 BETTER MEDICAL STUDENTS 1913 01:21:56,760 --> 01:22:00,600 PRIMARILY CARE PHYSICIANS WITH 1914 01:22:00,600 --> 01:22:02,400 -- RECEIVING SIGNIFICANT 1915 01:22:02,400 --> 01:22:09,800 TRAINING IN OSTEOPATIC MAN IP 1916 01:22:09,800 --> 01:22:10,840 YOU'LLATIVE THERAPIES AND TEAM 1917 01:22:10,840 --> 01:22:13,360 PHYSICIAN IN UNIVERSITY OF 1918 01:22:13,360 --> 01:22:15,920 TOLEDO AND CAME TO VIRGINIA TECH 1919 01:22:15,920 --> 01:22:19,120 AND -- AS WELL AS AT VIRGINIA 1920 01:22:19,120 --> 01:22:23,720 TECH AND DR. KORSHETZ WOULD BE 1921 01:22:23,720 --> 01:22:25,440 HAPPY TO KNOW WE ARE INJECTING 1922 01:22:25,440 --> 01:22:28,120 AND ASPIRATING AND DOING ALL 1923 01:22:28,120 --> 01:22:29,800 KINDS OF THINGS HAVEN'T FORGOT 1924 01:22:29,800 --> 01:22:35,760 TO TRAIN FELLOWS AND RESIDENTS 1925 01:22:35,760 --> 01:22:39,320 WITH PAIN ASPIRATION AND 1926 01:22:39,320 --> 01:22:39,840 INJECTION. 1927 01:22:39,840 --> 01:22:42,000 AND WORKING WITH SKI TEAM FOR 1928 01:22:42,000 --> 01:22:43,640 YEARS AND VAST MAJORITY OF 1929 01:22:43,640 --> 01:22:45,360 CAREER I HAD THE GREAT GOOD 1930 01:22:45,360 --> 01:22:48,440 FORTUNE TO WORK WITH LOTS OF 1931 01:22:48,440 --> 01:22:52,000 FERRARIS BUT ALSO I RUN INTO 1932 01:22:52,000 --> 01:22:53,120 SOME REAL TRAIN WRECKS. 1933 01:22:53,120 --> 01:22:55,040 IF WE CAN ADVANCE TO THE NEXT 1934 01:22:55,040 --> 01:22:58,440 SLIDE, I WOULD LIKE TO SHOW YOU 1935 01:22:58,440 --> 01:23:07,400 A LITTLE CLINICAL VERB AVIGNETT 1936 01:23:07,400 --> 01:23:11,040 THAT IS NOT A FERRARI BUT CHITTY 1937 01:23:11,040 --> 01:23:12,040 CHITTY BANG BANG AND PARTNER 1938 01:23:12,040 --> 01:23:14,360 THAT IS A FORMER FELLOW WORKING 1939 01:23:14,360 --> 01:23:15,960 WITH US HERE AND AT VIRGINIA 1940 01:23:15,960 --> 01:23:18,040 TECH AND THIS IS THE PATIENT 1941 01:23:18,040 --> 01:23:20,120 THAT WALKS INTO YOUR OFFICE. 1942 01:23:20,120 --> 01:23:25,360 SHOUTOUT TO DR. RUSSICK IN OG 1943 01:23:25,360 --> 01:23:27,240 AND EMPHASIS WHAT HAPPENS ON 1944 01:23:27,240 --> 01:23:28,760 CLINICAL SIDE OF THINGS PATIENT 1945 01:23:28,760 --> 01:23:30,680 COMES IN DON'T SAY I FEEL GREAT 1946 01:23:30,680 --> 01:23:32,400 BUT HAVE THIS PAIN AND HAVE TO 1947 01:23:32,400 --> 01:23:34,200 FIGURE IT OUT. THIS WOMAN CAME 1948 01:23:34,200 --> 01:23:35,880 IN AND WAS TOLD NOTHING COULD BE 1949 01:23:35,880 --> 01:23:37,840 DONE FOR HER PRETTY MUCH AND HAD 1950 01:23:37,840 --> 01:23:39,160 THAT HAPPEN A LOT OVER THE 1951 01:23:39,160 --> 01:23:42,200 COURSE OF MY CAREER. YOU SEE 1952 01:23:42,200 --> 01:23:45,360 SHE IS 58 AND HIGH BMI AND 1953 01:23:45,360 --> 01:23:47,160 UNABLE TO AMBULATE EXCEPT WITH A 1954 01:23:47,160 --> 01:23:49,160 WALKER WAND HE HAVE RADIO GRAPHS 1955 01:23:49,160 --> 01:23:52,160 HERE AND SHE HAD QUITE A BIT OF 1956 01:23:52,160 --> 01:23:53,680 LATERAL ANKLE PAIN AND FEELINGS 1957 01:23:53,680 --> 01:23:56,480 OF INSTABILITY. SHE HAS SEVERE 1958 01:23:56,480 --> 01:23:57,640 [INDISCERNIBLE] AS A LITTLE GIRL 1959 01:23:57,640 --> 01:24:00,160 SHE WAS TOLD SHE WAS NOT -- MANY 1960 01:24:00,160 --> 01:24:02,240 CLINICIANS ON THE CALL WE CALL 1961 01:24:02,240 --> 01:24:04,520 THIS THE MISERABLE MALALIGNMENT 1962 01:24:04,520 --> 01:24:06,760 SYNDROME THAT IS PROGRESSIVELY 1963 01:24:06,760 --> 01:24:09,040 WORSENED AND IMPORTANT TO DO A 1964 01:24:09,040 --> 01:24:10,040 REALLY GREAT FUNCTIONAL CLINICAL 1965 01:24:10,040 --> 01:24:13,000 EXAM TO FIND OUT WHAT IS GOING 1966 01:24:13,000 --> 01:24:14,800 ON AND WHAT IS BEATING UP THESE 1967 01:24:14,800 --> 01:24:16,360 TISSUES AND WHAT IS THE KINETIC 1968 01:24:16,360 --> 01:24:18,280 CHAIN THAT IS WORKING HERE AND 1969 01:24:18,280 --> 01:24:21,120 TRY TO SAY WHAT WE CAN DO TO 1970 01:24:21,120 --> 01:24:23,280 IMPROVE THAT KINETIC CHAIN THAT 1971 01:24:23,280 --> 01:24:25,520 IS A TYPICAL MULTIMODAL APPROACH 1972 01:24:25,520 --> 01:24:28,800 AND AREA OF GREATEST CONCERN WAS 1973 01:24:28,800 --> 01:24:37,000 AREA THAT [INDISCERNIBLE] LERRA 1974 01:24:37,000 --> 01:24:39,320 ON -- SHE DIDN'T HAVE ACUTE 1975 01:24:39,320 --> 01:24:41,360 SPRAIN AND SEE PRETTY 1976 01:24:41,360 --> 01:24:43,760 SUBSTANTIAL TEAR AND DYNAMIC 1977 01:24:43,760 --> 01:24:46,360 MOTION SHOWED SIGNIFICANT LAXITY 1978 01:24:46,360 --> 01:24:49,320 OF LATERAL LIGAMENT OF COMPLEX 1979 01:24:49,320 --> 01:24:52,040 AND FROM TREATMENT PERSPECTIVE 1980 01:24:52,040 --> 01:24:53,360 DID ULTRA SOUND GUIDE 3D 1981 01:24:53,360 --> 01:24:55,720 [INDISCERNIBLE] AND IN PLAINS 1982 01:24:55,720 --> 01:24:59,080 AND DISTANCE TO TENDON AND PRP 1983 01:24:59,080 --> 01:25:01,960 WAS INJECTED AND 2CCS OF MICROFA 1984 01:25:01,960 --> 01:25:04,080 THE THAT WAS MENTIONED YESTERDAY 1985 01:25:04,080 --> 01:25:07,920 AND FUNCTIONS PRIMARILY AS A 1986 01:25:07,920 --> 01:25:10,320 TISSUE SCAFFOLD AND APPROPRIATE 1987 01:25:10,320 --> 01:25:13,360 PROCEDURE REHAB AND PUT IN A 1988 01:25:13,360 --> 01:25:15,320 BOOT AND PHYSICAL THERAPY AND 1989 01:25:15,320 --> 01:25:18,600 ADDRESSED MULTIPLE MODAL ISSUES 1990 01:25:18,600 --> 01:25:20,880 BROUGHT UP BY DR. RUSIC 1991 01:25:20,880 --> 01:25:22,400 YESTERDAY AND FELT WAS IMPORTANT 1992 01:25:22,400 --> 01:25:24,680 COMPONENT OF THIS APPENDICULAR 1993 01:25:24,680 --> 01:25:27,040 AND SKELETAL MANIPULATIONS WERE 1994 01:25:27,040 --> 01:25:29,000 DONE TYPICALLY 2 TIMES A WEEK 1995 01:25:29,000 --> 01:25:30,640 SHE WAS IN PHYSICAL THERAPY OR 1996 01:25:30,640 --> 01:25:31,880 EXCUSE ME PHYSICAL THERAPY TWO 1997 01:25:31,880 --> 01:25:34,960 TIMES A WEEK AND OMT TWICE 1998 01:25:34,960 --> 01:25:37,040 MONTHLY AND SHE IMPROVED 1999 01:25:37,040 --> 01:25:38,760 SUBSTANTIALLY AND 12 WEEKS GATE 2000 01:25:38,760 --> 01:25:40,600 WAS REALLY IMPROVED WITH 2001 01:25:40,600 --> 01:25:43,720 MODERATE IMPROVEMENT TO LEFT 2002 01:25:43,720 --> 01:25:46,880 KNEE VALGUS YOU SEE 8 TO 10 2003 01:25:46,880 --> 01:25:49,680 DEGREES AND HAD MUCH BETTER 2004 01:25:49,680 --> 01:25:51,600 BILATERAL FOREFOOT SENSATION AND 2005 01:25:51,600 --> 01:25:53,400 MOTION WAS MUCH BETTER AND 2006 01:25:53,400 --> 01:25:54,960 OVERALL, AGAIN, SHE DID VERY 2007 01:25:54,960 --> 01:25:55,720 WELL. 2008 01:25:55,720 --> 01:25:57,080 NOW, THIS WAS A GREAT OUTCOME 2009 01:25:57,080 --> 01:25:59,680 FOR HER. SHE WAS REALLY 2010 01:25:59,680 --> 01:26:00,880 PLEASED. I THINK WHEN YOU LOOK 2011 01:26:00,880 --> 01:26:02,520 AT THIS CASE AND THINK ABOUT 2012 01:26:02,520 --> 01:26:04,960 WHAT WE HAVE SEEN YESTERDAY AND 2013 01:26:04,960 --> 01:26:06,360 TODAY, SHE PRETTY MUCH 2014 01:26:06,360 --> 01:26:07,680 DEMONSTRATES KIND OF ALL OF THE 2015 01:26:07,680 --> 01:26:09,880 STUFF THAT IS GOING ON THERE. 2016 01:26:09,880 --> 01:26:11,600 TYPICALLY IN THESE KINDS OF 2017 01:26:11,600 --> 01:26:14,200 CASES AND IN SPORTS MEDICINE WE 2018 01:26:14,200 --> 01:26:16,000 TAKE A KITCHEN SINK APPROACH AND 2019 01:26:16,000 --> 01:26:18,880 THROWING EVERYTHING WE CAN AT IT 2020 01:26:18,880 --> 01:26:19,840 MEDICAL THERAPY PHYSICAL THERAPY 2021 01:26:19,840 --> 01:26:22,240 DRY NEEDLING INJECTIONS AND PRP 2022 01:26:22,240 --> 01:26:24,320 AND WE DO ALL KINDS OF THINGS 2023 01:26:24,320 --> 01:26:28,000 BECAUSE WE ARE REALLY TAKING A 2024 01:26:28,000 --> 01:26:29,520 MULTIMODAL APPROACH. 2025 01:26:29,520 --> 01:26:32,280 >>THANK YOU DR. BROLINSON WE 2026 01:26:32,280 --> 01:26:34,040 CAN TALK ABOUT THE LAST SECTION 2027 01:26:34,040 --> 01:26:34,720 GETTING INTO PANEL DISCUSSION 2028 01:26:34,720 --> 01:26:35,840 AND WANT TO MAKE SURE WE HAVE 2029 01:26:35,840 --> 01:26:37,040 ENOUGH TIME TO ACTUALLY DISCUSS 2030 01:26:37,040 --> 01:26:38,560 SOME OF THE ISSUES. 2031 01:26:38,560 --> 01:26:40,680 THANKS SO MUCH. 2032 01:26:40,680 --> 01:26:41,520 >>GREAT. THANKS. 2033 01:26:41,520 --> 01:26:44,960 >>DR. BUTERA INTRODUCE 2034 01:26:44,960 --> 01:26:47,040 YOURSELVES PLEASE AND REMINDER 2 2035 01:26:47,040 --> 01:26:48,720 MINUTE INTRODUCTION AND TRY TO 2036 01:26:48,720 --> 01:26:49,320 BE BRIEF. 2037 01:26:49,320 --> 01:26:50,720 >>YES. NO PROBLEM. 2038 01:26:50,720 --> 01:26:52,960 >>ALL RIGHT. I WILL SHARE MY 2039 01:26:52,960 --> 01:26:57,040 SCREEN REAL QUICK. THERE WE GO. 2040 01:26:57,040 --> 01:26:58,440 THANK YOU SO MUCH FOR ASKING ME 2041 01:26:58,440 --> 01:27:00,680 TO BE PART OF THE PANEL AND WILL 2042 01:27:00,680 --> 01:27:04,600 LET AUDIENCE KNOW I'M A PHYSICAL 2043 01:27:04,600 --> 01:27:09,120 THERAPY IPT AT UNIVERSITY OF 2044 01:27:09,120 --> 01:27:17,240 DELAWARE WHAT STRUCK ME BASED ON 2045 01:27:17,240 --> 01:27:19,120 TODAY'S TALKS AND YESTERDAY'S 2046 01:27:19,120 --> 01:27:22,320 WAS THINKING ABOUT CHRONIC PAIN 2047 01:27:22,320 --> 01:27:24,240 IN PARTICULAR COMING TO JOINT 2048 01:27:24,240 --> 01:27:25,960 HEALTH THINKING ABOUT CHRONIC 2049 01:27:25,960 --> 01:27:28,160 PAIN AS A DISEASE IN AND OF 2050 01:27:28,160 --> 01:27:30,920 ITSELF WITH DISTINCT CHANGES 2051 01:27:30,920 --> 01:27:32,520 OCCURRING THROUGHOUT THE NERVOUS 2052 01:27:32,520 --> 01:27:34,200 SYSTEM. I HAVE BEEN REALLY 2053 01:27:34,200 --> 01:27:37,720 IMPRESSED WITH ALL OF THE TALK 2054 01:27:37,720 --> 01:27:41,200 AND REALLY I APPLAUD ORGANIZERS 2055 01:27:41,200 --> 01:27:44,240 OF WORKSHOP TO REALLY BE 2056 01:27:44,240 --> 01:27:45,160 THINKING ABOUT WHOLE JOINT 2057 01:27:45,160 --> 01:27:47,280 HEALTH. WHEN WE ARE THINKING 2058 01:27:47,280 --> 01:27:48,720 ABOUT TREATING PAIN CONDITIONS 2059 01:27:48,720 --> 01:27:51,280 WE ARE OFTEN TREATING THE ENTIRE 2060 01:27:51,280 --> 01:27:53,040 PERSON. 2061 01:27:53,040 --> 01:27:55,720 SO, I THINK THAT, THAT HAS BEEN 2062 01:27:55,720 --> 01:27:56,920 REALLY HIGHLIGHTED AND I WON'T 2063 01:27:56,920 --> 01:27:58,760 GO INTO ALL OF THESE THINGS THAT 2064 01:27:58,760 --> 01:28:01,520 WERE JUST SOME OF MY IMPORTANT 2065 01:28:01,520 --> 01:28:03,680 TAKEAWAYS THAT WE NEED TO REALLY 2066 01:28:03,680 --> 01:28:05,600 CONSIDER MULTIPLE PERIPHERAL AND 2067 01:28:05,600 --> 01:28:07,760 CENTRAL TARGETS WITH 2068 01:28:07,760 --> 01:28:08,960 INTERVENTIONS AND MANY 2069 01:28:08,960 --> 01:28:11,280 INTERVENTIONS OR DISCUSSIONS WE 2070 01:28:11,280 --> 01:28:14,200 HAVE HAD TODAY HAVE HAD REALLY 2071 01:28:14,200 --> 01:28:15,680 HIGHLIGHTED THERE IS MULTIPLE 2072 01:28:15,680 --> 01:28:16,040 TARGETS. 2073 01:28:16,040 --> 01:28:17,800 THESE MAY VARY ACROSS CONDITIONS 2074 01:28:17,800 --> 01:28:24,240 AND FOR EXAMPLE WITH AKEELIS 2075 01:28:24,240 --> 01:28:25,440 TENDONOPATHY THERE IS INCREASED 2076 01:28:25,440 --> 01:28:27,520 PAIN WITH LOADING AND NO PAIN 2077 01:28:27,520 --> 01:28:29,960 WHILE AT REST MAYBE. HOW CAN WE 2078 01:28:29,960 --> 01:28:33,120 TARGET MAYBE WE ARE TARGETING 2079 01:28:33,120 --> 01:28:34,560 TENDON IN PARTICULAR AND THOSE 2080 01:28:34,560 --> 01:28:36,800 AND IN THAT CONDITION VERSUS 2081 01:28:36,800 --> 01:28:41,520 THINGS LIKE NONSPECIFIC OR KNEE 2082 01:28:41,520 --> 01:28:43,120 OSTEOARTHRITIS THERE IS RESTING 2083 01:28:43,120 --> 01:28:44,480 PAIN AND KNEE PAIN AND ALSO WHAT 2084 01:28:44,480 --> 01:28:48,200 I TOOK AWAY FROM TODAY WITH SOME 2085 01:28:48,200 --> 01:28:49,720 CONSIDERATIONS OF APPLYING 2086 01:28:49,720 --> 01:28:52,400 EVIDENCE AND THERE WAS 2087 01:28:52,400 --> 01:28:53,360 DEFINITELY DISCUSSION IN THE 2088 01:28:53,360 --> 01:28:57,320 CHAT TODAY TO ADDRESS IN THE 2089 01:28:57,320 --> 01:29:00,320 PANEL DISCUSSION WITH REGARDS TO 2090 01:29:00,320 --> 01:29:02,760 OVERCOMING IMPLEMENTATION 2091 01:29:02,760 --> 01:29:04,360 BARRIERS AND CONSIDERING 2092 01:29:04,360 --> 01:29:06,920 INTERACTIONS BETWEEN THE 2093 01:29:06,920 --> 01:29:10,640 TREATMENT. THANK YOU. 2094 01:29:10,640 --> 01:29:13,000 >>THANK YOU. ALEX, YOU ARE 2095 01:29:13,000 --> 01:29:13,400 MUTED NOW. 2096 01:29:13,400 --> 01:29:17,360 >>SORRY MY BAD. 2097 01:29:17,360 --> 01:29:27,280 DR. BRONFORT YOU ARE NEXT AND 2098 01:29:27,280 --> 01:29:32,520 THANK YOU DR. BUTERA FOR 2099 01:29:32,520 --> 01:29:32,760 COMMENTS. 2100 01:29:32,760 --> 01:29:36,760 >>I'M A RESEARCH PROFESSOR AT 2101 01:29:36,760 --> 01:29:38,160 UNIVERSITY OF MINNESOTA AND 2102 01:29:38,160 --> 01:29:40,960 THANKS FOR THE SLIDES IS THIS 2103 01:29:40,960 --> 01:29:41,840 BRIEF SUMMARY SOMETHING YOU 2104 01:29:41,840 --> 01:29:42,160 NEED? 2105 01:29:42,160 --> 01:29:43,760 >>IT IS AVAILABLE IN THE 2106 01:29:43,760 --> 01:29:44,360 PROGRAM BOOK. 2107 01:29:44,360 --> 01:29:46,960 >>OKAY. NO NEED FOR THAT. 2108 01:29:46,960 --> 01:29:49,040 SO, MY PERSPECTIVE COMES FROM 2109 01:29:49,040 --> 01:29:50,640 BEING A CLINICAL TRIALIST FOR 2110 01:29:50,640 --> 01:29:52,840 MANY YEARS ASSESSING A NUMBER OF 2111 01:29:52,840 --> 01:29:55,960 DIFFERENT NONSURGICAL TREATMENTS 2112 01:29:55,960 --> 01:30:02,320 FOR BACK PAIN AND NECK PAIN. 2113 01:30:02,320 --> 01:30:05,240 IN THIS SPACE FACING UPHILL 2114 01:30:05,240 --> 01:30:08,680 BATTLE DUE TO DISABILITY AND 2115 01:30:08,680 --> 01:30:10,320 MUSCULODISORDERS ESTIMATED 2116 01:30:10,320 --> 01:30:12,520 INCREASED ESTIMATED 50 P RS IN 2117 01:30:12,520 --> 01:30:15,560 LAST 30 YEARS. 2118 01:30:15,560 --> 01:30:19,120 WITH INCREASINGLY OBESE AND 2119 01:30:19,120 --> 01:30:21,000 SEDENTARY AND AGING SOCIETIES IS 2120 01:30:21,000 --> 01:30:24,080 EXPECTED TO INCREASE MORE IN 2121 01:30:24,080 --> 01:30:25,360 YEARS TO COME AND AGAINST THIS 2122 01:30:25,360 --> 01:30:27,760 BACKDROP ONE COULD HARDLY SAY 2123 01:30:27,760 --> 01:30:30,080 THAT INTRODUCTION OF 2124 01:30:30,080 --> 01:30:31,360 BIOPSYCHOSOCIAL AND WHOLE PERSON 2125 01:30:31,360 --> 01:30:33,880 MODEL IN RESEARCH AND PRACTICE 2126 01:30:33,880 --> 01:30:35,800 AND MORE THAN 30 YEARS AGO HAS 2127 01:30:35,800 --> 01:30:41,160 BEEN A PUBLIC HEALTH SUCCESS. 2128 01:30:41,160 --> 01:30:43,560 IN FACT, ALONGSIDE WITH 2129 01:30:43,560 --> 01:30:44,560 INCREASING RATES OF DISABILITY 2130 01:30:44,560 --> 01:30:47,000 AND AGAINST GUIDELINE ADVICE ARE 2131 01:30:47,000 --> 01:30:49,360 INCREASED IN DIAGNOSTIC IMAGING 2132 01:30:49,360 --> 01:30:52,480 AND PROVISION AND MOST WILL I 2133 01:30:52,480 --> 01:30:53,600 BIOLOGICAL MONOTHERAPIES WITH 2134 01:30:53,600 --> 01:30:55,200 LIMITED EFFECTIVENESS AND 2135 01:30:55,200 --> 01:30:56,200 QUESTION THEREFORE IS WHETHER IT 2136 01:30:56,200 --> 01:30:59,240 IS A MODEL ITSELF THAT IS FAILED 2137 01:30:59,240 --> 01:31:01,600 TO DELIVER OVER THE SCIENTIFIC 2138 01:31:01,600 --> 01:31:04,200 AND HEALTH CARE COMMUNITIES HAVE 2139 01:31:04,200 --> 01:31:08,440 FAILED TO ADOPT THE MODEL. 2140 01:31:08,440 --> 01:31:10,920 IT IS NOT WIDELY RECOGNIZED THAT 2141 01:31:10,920 --> 01:31:13,320 BACK AND NECK PAIN ARE 2142 01:31:13,320 --> 01:31:14,400 ACCOMPLISHED CONDITIONS 2143 01:31:14,400 --> 01:31:16,520 INFLUENCED BY SEVERAL 2144 01:31:16,520 --> 01:31:17,320 INTERRELATED PHYSICAL 2145 01:31:17,320 --> 01:31:18,760 PSYCHOLOGICAL AND SOCIAL FACTORS 2146 01:31:18,760 --> 01:31:21,360 AND MOST TREATMENTS STILL FOCUS 2147 01:31:21,360 --> 01:31:23,960 ENTIRELY ON SYMPTOM MANAGEMENT 2148 01:31:23,960 --> 01:31:26,880 USING A ONE-SIZE FITS ALL BASED 2149 01:31:26,880 --> 01:31:30,120 ON MEAN DIFFERENCES OF 2150 01:31:30,120 --> 01:31:31,720 EFFECTIVENESS FROM SYSTEMATIC 2151 01:31:31,720 --> 01:31:33,280 REVIEWS AND GUIDELINES THAT 2152 01:31:33,280 --> 01:31:36,600 DOESN'T HELP CLINICIANS AND 2153 01:31:36,600 --> 01:31:39,640 PATIENTS VERY MUCH TO CHOOSE 2154 01:31:39,640 --> 01:31:43,480 WHICH TREATMENT TO TRY. 2155 01:31:43,480 --> 01:31:44,880 SO,UM THE TREATMENT IS 2156 01:31:44,880 --> 01:31:47,120 FREQUENTLY CHARACTERIZED BY 2157 01:31:47,120 --> 01:31:48,560 PERSISTIENT USE MARGINALLY 2158 01:31:48,560 --> 01:31:52,040 EFFECTIVE AND POTENTIALLY 2159 01:31:52,040 --> 01:31:55,000 HARMFUL THERAPIES LARGELY 2160 01:31:55,000 --> 01:31:56,280 IGNORING PSYCHOSOCIAL ASPECT OF 2161 01:31:56,280 --> 01:31:57,360 BACK PAIN. 2162 01:31:57,360 --> 01:32:03,000 FOR EXAMPLE, USE OF INJECTIONS 2163 01:32:03,000 --> 01:32:04,440 OPIOID PRESCRIPTIONS SPINAL 2164 01:32:04,440 --> 01:32:06,120 SURGERY INCREASED AT 2165 01:32:06,120 --> 01:32:07,720 ACCELERATING RATE IN PAST FEW 2166 01:32:07,720 --> 01:32:09,720 YEARS WITH LITTLE POSITIVE 2167 01:32:09,720 --> 01:32:13,280 IMPACT ON PATIENT OUTCOMES AND 2168 01:32:13,280 --> 01:32:14,560 PARTICULAR CONCERN THAT HAS BEEN 2169 01:32:14,560 --> 01:32:17,000 MENTIONED OVER-RELIANCE ON 2170 01:32:17,000 --> 01:32:19,720 OPIOIDS THAT IS USED BY 2171 01:32:19,720 --> 01:32:21,320 ESTIMATED 30% OF CHRONIC BACK 2172 01:32:21,320 --> 01:32:25,360 PAIN PATIENTS. 2173 01:32:25,360 --> 01:32:26,480 IN SPITE OF RECOMMENDATIONS 2174 01:32:26,480 --> 01:32:31,720 FROM CLINICAL GUIDELINES THAT 2175 01:32:31,720 --> 01:32:36,440 OTHER TYPES OF PHARMACOLOGICAL 2176 01:32:36,440 --> 01:32:38,240 TREATMENT OPTIONS WOULD BE MORE 2177 01:32:38,240 --> 01:32:40,040 APPROPRIATE AND REDUCING 2178 01:32:40,040 --> 01:32:42,520 BACKPAIN BURDEN PATIENTS SHOULD 2179 01:32:42,520 --> 01:32:45,880 HAVE GREATER ACCESS TO FRONTLINE 2180 01:32:45,880 --> 01:32:49,360 CARE ADDRESSING PHYSICAL AND 2181 01:32:49,360 --> 01:32:51,440 PSYCHOSOCIAL NEEDS ACCOMPLISHING 2182 01:32:51,440 --> 01:33:00,480 THIS HAS BEEN INCREASED STUDIES 2183 01:33:00,480 --> 01:33:04,600 MULTIMODAL INDIVIDUAL -- TO MEET 2184 01:33:04,600 --> 01:33:06,160 PATIENTS WHOLE PERSON NEEDS. 2185 01:33:06,160 --> 01:33:07,760 THAT IS MY -- I HAVE ANOTHER 2186 01:33:07,760 --> 01:33:11,840 THING I MIGHT BRING UP ABOUT 2187 01:33:11,840 --> 01:33:13,360 SOMETHING I HAVEN'T HEARD ABOUT 2188 01:33:13,360 --> 01:33:21,360 YET IN THIS WORKSHOP THAT IS 2189 01:33:21,360 --> 01:33:25,520 ONTOLOGIST MESOCHIMAL STEM CELL. 2190 01:33:25,520 --> 01:33:27,320 MAYBE SOMEONE HAS MENTIONED IT 2191 01:33:27,320 --> 01:33:29,280 OR MENTIONED IT IN PASSING AND 2192 01:33:29,280 --> 01:33:30,320 OTHERWISE MAYBE WE CAN TALK 2193 01:33:30,320 --> 01:33:31,720 ABOUT THAT A LITTLE BIT. 2194 01:33:31,720 --> 01:33:34,040 >>THANK YOU. LET'S FINISH 2195 01:33:34,040 --> 01:33:38,200 INTRODUCING THE PANELISTS. 2196 01:33:38,200 --> 01:33:40,760 DR. GOERTZ. 2197 01:33:40,760 --> 01:33:43,240 >>MORNING, EVERYONE. IT IS A 2198 01:33:43,240 --> 01:33:44,520 PLEASURE TO BE WITH YOU AND HAVE 2199 01:33:44,520 --> 01:33:46,440 AN OPPORTUNITY TO ATTEND THIS 2200 01:33:46,440 --> 01:33:48,280 WORKSHOP AND THANKING NIH 2201 01:33:48,280 --> 01:33:51,360 ORGANIZERS AND REALLY ALL OF THE 2202 01:33:51,360 --> 01:33:54,320 PANELISTS FOR YOUR EXCELLENT 2203 01:33:54,320 --> 01:33:54,680 PRESENTATIONS. 2204 01:33:54,680 --> 01:33:57,000 THE PERSPECTIVE I BRING TO THIS 2205 01:33:57,000 --> 01:34:01,000 DISCUSSION IS CLIN KALILY I AM A 2206 01:34:01,000 --> 01:34:05,200 DOCTOR OF CHIROPRACTIC AND MY 2207 01:34:05,200 --> 01:34:08,000 FOCUS NOW AT DUKE UNIVERSITY 2208 01:34:08,000 --> 01:34:10,640 SCHOOL OF MEDICINE IS REALLY 2209 01:34:10,640 --> 01:34:12,680 BIMODAL AND I SPEND PART OF MY 2210 01:34:12,680 --> 01:34:15,000 TIME TRYING TO FIGURE OUT HOW WE 2211 01:34:15,000 --> 01:34:19,520 CAN FILL GAPS IN KNOWLEDGE 2212 01:34:19,520 --> 01:34:23,640 REGARDING BEST PRACTICES FOR 2213 01:34:23,640 --> 01:34:24,360 NONPHARMACOLOGICAL TREATMENT 2214 01:34:24,360 --> 01:34:28,040 APPROACHES MANAGEMENT OF JOINT 2215 01:34:28,040 --> 01:34:30,120 RELATED DISORDERS WITH FOCUS ON 2216 01:34:30,120 --> 01:34:32,720 LOW BACK PAIN AND OTHER PART OF 2217 01:34:32,720 --> 01:34:34,720 MY POSITION IS TRYING TO FIGURE 2218 01:34:34,720 --> 01:34:36,880 OUT HOW WE IMPLEMENT KNOWLEDGE 2219 01:34:36,880 --> 01:34:38,320 THAT WE ALREADY KNOW. 2220 01:34:38,320 --> 01:34:41,160 SO, I HAVE THREE NIH FUNDED 2221 01:34:41,160 --> 01:34:42,760 CLINICAL TRIALS THAT I'M 2222 01:34:42,760 --> 01:34:43,720 CURRENTLY WORKING ON AND THEY 2223 01:34:43,720 --> 01:34:46,800 RANGE FROM TRYING TO FIGURE OUT 2224 01:34:46,800 --> 01:34:50,320 DOSING OF CHIROPRACTIC IN 2225 01:34:50,320 --> 01:34:51,760 VETERANS WITH LOW BACK PAINS AND 2226 01:34:51,760 --> 01:34:55,320 HOW MANY VISITS SHOULD THEY OR 2227 01:34:55,320 --> 01:34:57,360 ARE OPTIMAL TO TRY TO DISCOVER 2228 01:34:57,360 --> 01:34:59,400 WHAT HAPPENS IF WE ASK PATIENTS 2229 01:34:59,400 --> 01:35:01,360 WHO ARE CALLING LARGE ACADEMIC 2230 01:35:01,360 --> 01:35:03,160 HEALTH CENTER TO MAKE 2231 01:35:03,160 --> 01:35:04,880 APPOINTMENTS WITH PRIMARY CARE 2232 01:35:04,880 --> 01:35:07,720 PHYSICIAN AND IF WILLING TO SEE 2233 01:35:07,720 --> 01:35:10,080 A CHIROPRACTOR OR PHYSICAL 2234 01:35:10,080 --> 01:35:12,240 THERAPIST AND FIRST LOOKING AT 2235 01:35:12,240 --> 01:35:13,640 HAVING A PLANNING GRANT AND 2236 01:35:13,640 --> 01:35:16,280 LOOKING AT WHAT HAPPENS IF WE 2237 01:35:16,280 --> 01:35:18,960 ASK PATIENTS TO USE A 2238 01:35:18,960 --> 01:35:21,200 MINDFULNESS APP AND HAVACU 2239 01:35:21,200 --> 01:35:23,200 PUNCTURE BEFORE AND AFTER SPINE 2240 01:35:23,200 --> 01:35:23,480 SURGERY. 2241 01:35:23,480 --> 01:35:25,640 AND SO THAT IS THE RESEARCH SIDE 2242 01:35:25,640 --> 01:35:29,360 OF WHAT I'M WORKING ON IN THE 2243 01:35:29,360 --> 01:35:30,080 CLINICAL IMPLEMENTATION SIDE. 2244 01:35:30,080 --> 01:35:32,480 WE ARE COMMITTED TO IMPLEMENTING 2245 01:35:32,480 --> 01:35:34,360 AMERICAN COLLEGE OF PHYSICIAN 2246 01:35:34,360 --> 01:35:36,040 GUIDELINE FOR LOW BACK PAIN 2247 01:35:36,040 --> 01:35:38,960 WITHIN DUKE UNIVERSITY HEALTH 2248 01:35:38,960 --> 01:35:41,040 SYSTEM AND IT RECOMMENDS 2249 01:35:41,040 --> 01:35:42,280 NONPHARMACOLOGICAL TREATMENT 2250 01:35:42,280 --> 01:35:43,760 APPROACHES PRIOR TO OTHER 2251 01:35:43,760 --> 01:35:45,520 TREATMENTS AND SPECIFICALLY 2252 01:35:45,520 --> 01:35:46,680 PRESCRIPTION MEDICATIONS. 2253 01:35:46,680 --> 01:35:50,200 WE HAVE DEVELOPED A NUMBER OF 2254 01:35:50,200 --> 01:35:52,920 EDUCATION MODULES AND TOOLS FOR 2255 01:35:52,920 --> 01:35:55,200 BOTH CLINICIANS AND PATIENTS AND 2256 01:35:55,200 --> 01:35:57,400 WE HAVE DEVELOPED ALSO A 2257 01:35:57,400 --> 01:35:59,200 CLINICAL DATA REGISTRY FOR LOW 2258 01:35:59,200 --> 01:36:02,680 BACK PAIN THAT ALLOWS US TO 2259 01:36:02,680 --> 01:36:04,320 TRACK UTILIZATION AND OUTCOMES 2260 01:36:04,320 --> 01:36:07,200 AND TO MEASURE WHETHER THEY ARE 2261 01:36:07,200 --> 01:36:08,680 CONSISTENT WITH BEST PRACTICES 2262 01:36:08,680 --> 01:36:10,400 AND TO MEASURE TRENDS OVER TIME. 2263 01:36:10,400 --> 01:36:13,360 WE ARE STILL IN THE EARLY PHASES 2264 01:36:13,360 --> 01:36:15,120 OF IMPLEMENTATION. 2265 01:36:15,120 --> 01:36:19,760 OUR EARLY INDICATIONS ARE THAT 2266 01:36:19,760 --> 01:36:22,160 IT IS POSSIBLE TO -- TO CHANGE 2267 01:36:22,160 --> 01:36:25,600 HEALTH CARE DELIVERY WHEN IT CAN 2268 01:36:25,600 --> 01:36:27,840 BE DIFFICULT. 2269 01:36:27,840 --> 01:36:28,320 >>OKAY. 2270 01:36:28,320 --> 01:36:32,080 >>MY -- I HAVE 10 QUICK 2271 01:36:32,080 --> 01:36:33,400 TAKEAWAYS FROM THIS CONFERENCE 2272 01:36:33,400 --> 01:36:35,800 SO FAR. 2273 01:36:35,800 --> 01:36:38,040 THE FIRST IS THAT WHOLE JOINT 2274 01:36:38,040 --> 01:36:38,240 PAIN. 2275 01:36:38,240 --> 01:36:40,680 >>I THINK WE SHOULD DISCUSS 2276 01:36:40,680 --> 01:36:42,080 TAKEAWAYS AS PART OF THE 2277 01:36:42,080 --> 01:36:43,680 DISCUSSION AND FINISH LAST 2278 01:36:43,680 --> 01:36:47,160 INTRODUCTION WITH THE LAST 2279 01:36:47,160 --> 01:36:48,280 PANELIST, PLEASE. 2280 01:36:48,280 --> 01:36:50,200 >>GOOD MORNING, EVERYBODY. 2281 01:36:50,200 --> 01:36:52,760 I WILL TRY TO KEEP COMMENTS 2282 01:36:52,760 --> 01:36:55,760 SUPER BRIEF. WE HAVE HOPEFULLY 2283 01:36:55,760 --> 01:37:00,280 ROBUST CONVERSATIONS I'M BRIAN 2284 01:37:00,280 --> 01:37:02,040 NOEHREN AND WOULD LIKE TO THANK 2285 01:37:02,040 --> 01:37:03,520 CONFERENCE ORGANIZERS FOR 2286 01:37:03,520 --> 01:37:05,400 INVITING ME TO JOIN THIS PANEL 2287 01:37:05,400 --> 01:37:07,640 AND LEARNED SO MUCH FROM 2288 01:37:07,640 --> 01:37:08,040 LISTENING. 2289 01:37:08,040 --> 01:37:10,280 I WANT TO CENTER THOUGHTS 2290 01:37:10,280 --> 01:37:11,640 PROVIDED HERE ON OBSERVATIONS I 2291 01:37:11,640 --> 01:37:14,240 HAD FROM LISTENING TO EVERYBODY. 2292 01:37:14,240 --> 01:37:15,880 FIRST, IN EXERCISE TRIALS WE 2293 01:37:15,880 --> 01:37:17,480 HAVE NOT ALWAYS ACCOUNTED FOR 2294 01:37:17,480 --> 01:37:19,560 VARIOUS SOURCES OF PAIN OR 2295 01:37:19,560 --> 01:37:22,320 ORIGIN OF DEVELOPMENT OF 2296 01:37:22,320 --> 01:37:22,920 OSTEOARTHRITIS TO LEVEL 2297 01:37:22,920 --> 01:37:24,120 DISCUSSED YESTERDAY IN THE 2298 01:37:24,120 --> 01:37:25,920 CONFERENCE AND BRING IT UP AS 2299 01:37:25,920 --> 01:37:28,200 RECENT REVIEW IN LANCET CALLED 2300 01:37:28,200 --> 01:37:29,840 IN QUESTION WHETHER EXERCISE IS 2301 01:37:29,840 --> 01:37:32,520 EFFECTIVE VERSUS INTENTIONAL 2302 01:37:32,520 --> 01:37:35,160 CONTROL TREATING CHRONIC PAIN 2303 01:37:35,160 --> 01:37:37,760 CONDITIONS ESPECIALLY 2304 01:37:37,760 --> 01:37:38,800 OSTEOARTHRITIS AND THIS HAS LED 2305 01:37:38,800 --> 01:37:41,600 TO GROUPS PUBLISHING EDITORIALS 2306 01:37:41,600 --> 01:37:43,760 ALONG THE SIMILAR LINES AND IN 2307 01:37:43,760 --> 01:37:45,120 TERMS OF A QUESTION FOR THE 2308 01:37:45,120 --> 01:37:49,400 GROUP, I WONDER IS IT POSSIBLE 2309 01:37:49,400 --> 01:37:51,200 TO HAVE INTERVENTIONS TO 2310 01:37:51,200 --> 01:37:52,920 SUBGROUPS AND IDENTIFY 2311 01:37:52,920 --> 01:37:54,720 RESPONDERS AND NONRESPONDERS TO 2312 01:37:54,720 --> 01:37:57,920 EXERCISE TO TARGET INTERVENTIONS 2313 01:37:57,920 --> 01:37:58,160 BETTER. 2314 01:37:58,160 --> 01:38:00,200 IS IT TRULY NOT THE SAME EFFECT 2315 01:38:00,200 --> 01:38:03,760 WE HOPE FOR BRINGING US TO LEVEL 2316 01:38:03,760 --> 01:38:05,000 OF METAANALYSIS AND OTHER TWO 2317 01:38:05,000 --> 01:38:06,440 QUICK POINTS ALONG THOSE LINES 2318 01:38:06,440 --> 01:38:08,600 IS I HAVE BEEN WONDERING 2319 01:38:08,600 --> 01:38:09,960 LISTENING TO EVERYONE ARE THERE 2320 01:38:09,960 --> 01:38:11,680 WINDOWS THAT PEOPLE MIGHT BE 2321 01:38:11,680 --> 01:38:13,400 MORE RESPONSIVE TO A TREATMENT 2322 01:38:13,400 --> 01:38:15,240 THAT WE DIRECT TREATMENTS TO 2323 01:38:15,240 --> 01:38:17,160 BASED UPON POTENTIAL SYMPTOM 2324 01:38:17,160 --> 01:38:19,480 STATE AND BUILDING ON THE GREAT 2325 01:38:19,480 --> 01:38:22,160 TALK, COULD WE DISCUSS MORE 2326 01:38:22,160 --> 01:38:24,400 ABOUT [INDISCERNIBLE] OF FUTURE 2327 01:38:24,400 --> 01:38:25,720 TRIALS AND SOME OF THE 2328 01:38:25,720 --> 01:38:28,040 CHALLENGES THAT FOR EXAMPLE THE 2329 01:38:28,040 --> 01:38:29,440 CONTROL GROUP AND WHAT IT SHOULD 2330 01:38:29,440 --> 01:38:31,440 LOOK LIKE AND CONTROLLING FOR 2331 01:38:31,440 --> 01:38:33,400 SOURCES OF BIAS AND NEED FOR 2332 01:38:33,400 --> 01:38:35,280 FUNDING FOR LARGER TRIALS THAT 2333 01:38:35,280 --> 01:38:38,360 ARE REALLY QUITE EXPENSIVE AND 2334 01:38:38,360 --> 01:38:40,160 HARD TO PULL OFF. MY LAST POINT 2335 01:38:40,160 --> 01:38:42,800 THAT I JUST WOULD LIKE TO BRING 2336 01:38:42,800 --> 01:38:44,440 UP REAL QUICK IS AS WE EXPLORE 2337 01:38:44,440 --> 01:38:46,040 AND TALK ABOUT TREATMENTS IN 2338 01:38:46,040 --> 01:38:47,680 THIS SESSION I WONDER ABOUT 2339 01:38:47,680 --> 01:38:51,120 APPROACHES TO CLINICAL TRIALS 2340 01:38:51,120 --> 01:38:56,560 WHERE WE -- MANAGED TO MUTE 2341 01:38:56,560 --> 01:38:59,560 MYSELF AND WHERE WE INTEGRATE 2342 01:38:59,560 --> 01:39:01,360 PSYCHOSOCIAL AND PHYSICAL 2343 01:39:01,360 --> 01:39:02,200 INTERVENTIONS TOGETHER AND GIVEN 2344 01:39:02,200 --> 01:39:05,840 ALL WE KNOW ABOUT PSYCHOSOCIAL 2345 01:39:05,840 --> 01:39:08,400 ASPECTS OF OSTEOARTHRITIS AND 2346 01:39:08,400 --> 01:39:10,160 OTHER CONDITIONS RELATED TO PAIN 2347 01:39:10,160 --> 01:39:13,000 WHAT WE SHOULD BE TREATING IN 2348 01:39:13,000 --> 01:39:15,000 EXERCISED TRIALS AND BELIEVE A 2349 01:39:15,000 --> 01:39:16,440 POINT WAS RAISED YESTERDAY AND 2350 01:39:16,440 --> 01:39:18,080 CAN'T RECALL PERSON THAT BROUGHT 2351 01:39:18,080 --> 01:39:19,680 IT UP TO GIVE APPROPRIATE CREDIT 2352 01:39:19,680 --> 01:39:21,400 AND ALONG SAME LINES WHAT THEY 2353 01:39:21,400 --> 01:39:24,080 BROUGHT UP IN TERMS OF PHYSICAL 2354 01:39:24,080 --> 01:39:26,160 INTERVENTION SHOULD -- WE ARE 2355 01:39:26,160 --> 01:39:28,000 LOOKING TO COMBINE THESE IN 2356 01:39:28,000 --> 01:39:29,080 FUTURE TRIAL DESIGNS AND WOULD 2357 01:39:29,080 --> 01:39:30,960 LOVE TO HEAR FROM THE SPEAKERS 2358 01:39:30,960 --> 01:39:32,520 TO SPECULATE ABOUT THEIR 2359 01:39:32,520 --> 01:39:33,320 THOUGHTS ON THIS. 2360 01:39:33,320 --> 01:39:33,800 THANK YOU. 2361 01:39:33,800 --> 01:39:35,400 >>THANK YOU VERY MUCH. I WOULD 2362 01:39:35,400 --> 01:39:41,200 LIKE TO INTRODUCE QUICKLY NIH 2363 01:39:41,200 --> 01:39:43,760 CO-CHAIR DR. MICHAEL OSHH CHIN 2364 01:39:43,760 --> 01:39:45,400 SKI THAT IS OFFICE OF 2365 01:39:45,400 --> 01:39:47,000 PRECLINICAL PAIN RESEARCH 2366 01:39:47,000 --> 01:39:48,000 HELPING IT GUIDE MODERATION 2367 01:39:48,000 --> 01:39:49,880 SESSION WITH ME. I THINK 2368 01:39:49,880 --> 01:39:51,200 HOWEVER A LITTLE EXERCISE 2369 01:39:51,200 --> 01:39:53,880 CHAIR'S PRIORITY FOLLOWING UP ON 2370 01:39:53,880 --> 01:39:57,000 DR. NOEHREN'S FIRST QUESTION 2371 01:39:57,000 --> 01:39:58,920 WITH THESE EXERCISE TRIALS, IS 2372 01:39:58,920 --> 01:40:01,680 IT -- SHOULD WE BE TARGETING 2373 01:40:01,680 --> 01:40:05,080 SPECIFIC SUBPOPULATIONS AND NOT 2374 01:40:05,080 --> 01:40:08,840 REALLY A ONE-SIZE FITS ALL AND 2375 01:40:08,840 --> 01:40:12,640 WHERE IS CRITICAL WINDOW TO 2376 01:40:12,640 --> 01:40:14,760 EXERCISE THERAPY AND SHOWING 2377 01:40:14,760 --> 01:40:15,840 DIMINISHING RETURNS OVER TIME 2378 01:40:15,840 --> 01:40:17,360 AND WHAT ARE COMPARATIVE GROUPS 2379 01:40:17,360 --> 01:40:19,760 TO INCLUDE IN AN EXERCISE TRIAL 2380 01:40:19,760 --> 01:40:21,240 OR PHYSICAL THERAPY TRIAL AND 2381 01:40:21,240 --> 01:40:23,600 SHOULD THIS -- SHOULD IT BE 2382 01:40:23,600 --> 01:40:25,400 SUFFICIENT TO DEMONSTRATE THAT 2383 01:40:25,400 --> 01:40:28,320 EXERCISE IS EFFECTIVE OR IS IT 2384 01:40:28,320 --> 01:40:30,520 EFFECTIVE ALONE IN TREATING 2385 01:40:30,520 --> 01:40:32,040 CHRONIC PAIN OR BE COMBIN 2386 01:40:32,040 --> 01:40:33,160 ATORIAL WITH OTHER 2387 01:40:33,160 --> 01:40:33,800 INTERVENTIONS? 2388 01:40:33,800 --> 01:40:35,840 I WOULD LIKE TO DO A BROAD SET 2389 01:40:35,840 --> 01:40:37,160 OF QUESTIONS TO INVITE PANELISTS 2390 01:40:37,160 --> 01:40:40,760 AND SPEAKERS TO COME ON CAMERA. 2391 01:40:40,760 --> 01:40:44,040 IF YOU HAVE SOMETHING TO ADD OR 2392 01:40:44,040 --> 01:40:46,520 RESPOND, PLEASE RAISE YOUR HAND. 2393 01:40:46,520 --> 01:40:51,560 >>ALEX, I SEE DR. MESSIER 2394 01:40:51,560 --> 01:40:52,480 BROUGHT UP HIS VIDEO. 2395 01:40:52,480 --> 01:40:54,440 >>GREAT. WOULD YOU LIKE TO 2396 01:40:54,440 --> 01:40:54,800 RESPOND? 2397 01:40:54,800 --> 01:40:58,120 >>SURE. I AM NOT SURE WITH SO 2398 01:40:58,120 --> 01:41:00,560 MUCH WHAT TO DO WITH THE 2399 01:41:00,560 --> 01:41:01,840 INTERVENTION AS IT IS WITH WHAT 2400 01:41:01,840 --> 01:41:05,000 TO DO WITH THE CONTROL GROUP. 2401 01:41:05,000 --> 01:41:08,880 I AM -- BACK IN 1997 WHEN WE 2402 01:41:08,880 --> 01:41:12,280 PUBLISHED THE FAST TRIAL, YOU 2403 01:41:12,280 --> 01:41:14,080 COULD SEE AND -- THAT THE -- 2404 01:41:14,080 --> 01:41:16,880 THAT THE TWO EXERCISE GROUPS GOT 2405 01:41:16,880 --> 01:41:19,000 A LITTLE BETTER. 2406 01:41:19,000 --> 01:41:21,640 CONTROL GROUP GOT A LOT WORSE. 2407 01:41:21,640 --> 01:41:23,720 ALL RIGHT? AND I HAD PEOPLE SAY 2408 01:41:23,720 --> 01:41:26,280 YOU ARE LUCKY THAT THE CONTROL 2409 01:41:26,280 --> 01:41:27,640 GROUP DIDN'T DO WELL. 2410 01:41:27,640 --> 01:41:29,840 THEY WERE 65 YEARS AND OLDER AT 2411 01:41:29,840 --> 01:41:32,000 THAT POINT. I SAID, WELL, THIS 2412 01:41:32,000 --> 01:41:33,400 IS WHAT HAPPENS TO PEOPLE THAT 2413 01:41:33,400 --> 01:41:37,360 ARE 65 AND OLDER IF THEY DON'T 2414 01:41:37,360 --> 01:41:37,880 DO ANYTHING. 2415 01:41:37,880 --> 01:41:38,640 THEY GET WORSE. 2416 01:41:38,640 --> 01:41:43,280 FROM A PUBLIC HEALTH 2417 01:41:43,280 --> 01:41:44,200 PERSPECTIVE. 2418 01:41:44,200 --> 01:41:47,320 BUT, AS WE HAVE GONE ON, OUR 2419 01:41:47,320 --> 01:41:50,920 STUDIES HAVE GOTTEN YOUNGER AND 2420 01:41:50,920 --> 01:41:52,240 YOUNGER. 2421 01:41:52,240 --> 01:41:54,320 OBESITY HAS DRIVEN 2422 01:41:54,320 --> 01:41:55,960 OSTEOARTHRITIS DOWN IN AGE NOW. 2423 01:41:55,960 --> 01:41:58,800 WHAT WE USED TO SEE AT 65 WE SEE 2424 01:41:58,800 --> 01:42:02,640 NOW AT 50 OR 45. 2425 01:42:02,640 --> 01:42:07,840 AND SO THAT FIRST TRIAL, IT WAS 2426 01:42:07,840 --> 01:42:10,240 A CONTROL GROUP NOT ATTENTION 2427 01:42:10,240 --> 01:42:12,040 CONTROL GROUP AND HAD VERY 2428 01:42:12,040 --> 01:42:13,560 LITTLE INTERACTION WITH THE 2429 01:42:13,560 --> 01:42:14,720 CONTROL GROUP. 2430 01:42:14,720 --> 01:42:16,440 ONE, FACE-TO-FACE A MONTH FOR 2431 01:42:16,440 --> 01:42:18,160 THE FIRST THREE MONTHS AND AFTER 2432 01:42:18,160 --> 01:42:21,360 THAT FROM MONTHS 4 TO 18, THERE 2433 01:42:21,360 --> 01:42:23,160 WAS JUST A PHONE CALL. 2434 01:42:23,160 --> 01:42:25,560 AS WE HAVE GONE ON, WE HAVE DONE 2435 01:42:25,560 --> 01:42:28,480 MORE ATTENTION CONTROL. 2436 01:42:28,480 --> 01:42:30,600 SO, WE HAVE -- WE PAY MORE 2437 01:42:30,600 --> 01:42:33,560 ATTENTION TO THE CONTROL GROUP. 2438 01:42:33,560 --> 01:42:37,080 I THINK WHAT IS HAPPENING IS 2439 01:42:37,080 --> 01:42:39,520 THAT WE SEE THE CONTROL GROUP 2440 01:42:39,520 --> 01:42:43,360 GETTING BETTER AS WELL. 25 TO 2441 01:42:43,360 --> 01:42:46,280 45% REDUCTION IN PAIN THAT IS 2442 01:42:46,280 --> 01:42:47,840 PRETTY MUCH WHAT EXERCISE DOES. 2443 01:42:47,840 --> 01:42:50,400 SO, MY FEELING IS THAT A GOOD 2444 01:42:50,400 --> 01:42:55,720 PART OF EXERCISE IN THIS 2445 01:42:55,720 --> 01:42:57,160 POPULATION, RESULTS ARE MORE THE 2446 01:42:57,160 --> 01:42:59,200 FACT THAT WE ARE PAYING 2447 01:42:59,200 --> 01:43:01,040 ATTENTION TO PEOPLE NOT THE 2448 01:43:01,040 --> 01:43:02,240 EXERCISE ITSELF. 2449 01:43:02,240 --> 01:43:06,240 IT IS MORE CONTEXTUAL. 2450 01:43:06,240 --> 01:43:08,120 REALLY TO GET A GOOD BANG FOR 2451 01:43:08,120 --> 01:43:10,240 YOUR BUCK WITH PAIN REDUCTION, 2452 01:43:10,240 --> 01:43:13,160 YOU HAVE TO ADD WEIGHT LOSS TO 2453 01:43:13,160 --> 01:43:13,520 THE EXERCISE. 2454 01:43:13,520 --> 01:43:17,640 >>OKAY. THANK YOU DR. MESSIER. 2455 01:43:17,640 --> 01:43:21,280 I SEE TWO HANDS RAISED. 2456 01:43:21,280 --> 01:43:23,480 >>YEAH. OKAY. SO, MY THOUGHTS 2457 01:43:23,480 --> 01:43:25,680 WERE -- I AGREE ABOUT WHAT WE DO 2458 01:43:25,680 --> 01:43:27,880 WITH THE CONTROL GROUP AND WHAT 2459 01:43:27,880 --> 01:43:29,480 I'M THINKING ABOUT IS, YES. WE 2460 01:43:29,480 --> 01:43:32,040 HAVE TO DO THEM AS PART OF A 2461 01:43:32,040 --> 01:43:33,640 STANDARD OF CARE THAT WE ARE 2462 01:43:33,640 --> 01:43:35,440 ALREADY DOING AND WE NEED TO NOT 2463 01:43:35,440 --> 01:43:38,680 DO THEM AS INDEPENDENT ENTITIES 2464 01:43:38,680 --> 01:43:40,880 IN THESE TRIALS ANYMORE. NOT 2465 01:43:40,880 --> 01:43:42,480 HOW PEOPLE RECEIVE TREATMENT AND 2466 01:43:42,480 --> 01:43:44,240 NOT HOW THEY WORK FORWARD IN 2467 01:43:44,240 --> 01:43:45,600 THEIR TREATMENT. IF IT WILL 2468 01:43:45,600 --> 01:43:47,120 WORK, IT WILL HAVE TO BE DONE. 2469 01:43:47,120 --> 01:43:49,080 I DON'T THINK WE HAVE ENOUGH 2470 01:43:49,080 --> 01:43:50,840 DATA YET TO KNOW WHETHER OR NOT 2471 01:43:50,840 --> 01:43:53,000 WE HAVE SUBGROUPINGS AND WE NEED 2472 01:43:53,000 --> 01:43:54,920 LARGE ENOUGH TRIALS THAT WE CAN 2473 01:43:54,920 --> 01:43:58,960 THEN DO RESPONDER ANALYSIS. 2474 01:43:58,960 --> 01:44:00,920 BRIAN BROUGHT UP A REALLY NICE 2475 01:44:00,920 --> 01:44:02,280 QUESTION THAT WE NEED THE MONEY 2476 01:44:02,280 --> 01:44:04,240 TO DO THOSE TRIALS; RIGHT? 2477 01:44:04,240 --> 01:44:06,640 IN ORDER TO DO THEM OF 2478 01:44:06,640 --> 01:44:07,840 SUFFICIENT QUALITY SO WE CAN 2479 01:44:07,840 --> 01:44:09,960 BEGIN TO DO RESPONDER ANALYSIS. 2480 01:44:09,960 --> 01:44:11,720 IF WE DON'T KNOW WHO RESPONDS TO 2481 01:44:11,720 --> 01:44:13,080 WHAT TREATMENTS, WE CAN'T BEGIN 2482 01:44:13,080 --> 01:44:15,840 TO PICK THOSE THAT WILL BE THE 2483 01:44:15,840 --> 01:44:17,960 BEST RESPONDERS OR WHICH 2484 01:44:17,960 --> 01:44:19,640 SUBGROUPS WE HAVE TO BE WORKING 2485 01:44:19,640 --> 01:44:20,000 ON. 2486 01:44:20,000 --> 01:44:22,640 WE DON'T HAVE THAT FOR EXERCISE 2487 01:44:22,640 --> 01:44:25,160 AND OA YET AND WE DON'T HAVE IT 2488 01:44:25,160 --> 01:44:26,480 FOR EXERCISE AND PROBABLY 2489 01:44:26,480 --> 01:44:29,600 ANYTHING YET AT THAT LEVEL. DR. 2490 01:44:29,600 --> 01:44:32,280 MESSIER IS DOING LARGE STUDIES 2491 01:44:32,280 --> 01:44:34,320 AND PERHAPS SECONDARY ANALYSIS 2492 01:44:34,320 --> 01:44:36,280 ON HIS STUDIES WILL BE ABLE TO 2493 01:44:36,280 --> 01:44:37,880 HELP US IDENTIFY SOME OF THE 2494 01:44:37,880 --> 01:44:41,760 FACTORS AND WE NEED MORE TRIALS 2495 01:44:41,760 --> 01:44:52,160 OUT THERE DOING THAT. 2496 01:44:55,080 --> 01:45:01,960 >>ALEX I'M SEEING DR. RAGOVHN'S 2497 01:45:01,960 --> 01:45:02,920 HAND WAS RAISED. 2498 01:45:02,920 --> 01:45:06,720 >>THANK YOU. I WANTED TO SHARE 2499 01:45:06,720 --> 01:45:10,320 A PERSPECTIVE FROM 2500 01:45:10,320 --> 01:45:12,000 NEUROLOGICALLY IMPAIRED 2501 01:45:12,000 --> 01:45:15,360 POPULATION IN TERMS OF CRITICAL 2502 01:45:15,360 --> 01:45:17,040 WINDOW WE FIND THAT EXERCISE IS 2503 01:45:17,040 --> 01:45:19,880 ALSO VERY CRITICAL IN 2504 01:45:19,880 --> 01:45:20,720 NEUROLOGICAL POPULATION. 2505 01:45:20,720 --> 01:45:23,040 IT RELEASES GROWTH FACTORS AND 2506 01:45:23,040 --> 01:45:25,440 QUESTION IS WHEN DO YOU GET THAT 2507 01:45:25,440 --> 01:45:25,800 INTERVENTION? 2508 01:45:25,800 --> 01:45:28,120 AND WHAT -- YOU KNOW, SOME OF 2509 01:45:28,120 --> 01:45:31,280 OUR DATA SHOWED THAT I SHARED IS 2510 01:45:31,280 --> 01:45:34,640 THAT IMMOBILITY LEADS TO CHANGES 2511 01:45:34,640 --> 01:45:38,880 IN THE TISSUE STRUCTURE. 2512 01:45:38,880 --> 01:45:40,360 WE WANT TO PREVENT THOSE CHANGES 2513 01:45:40,360 --> 01:45:42,000 THAT WOULD BE REALLY IMPORTANT 2514 01:45:42,000 --> 01:45:43,960 TO GIVE THOSE EARLY AND 2515 01:45:43,960 --> 01:45:47,280 INTERVENTIONS EARLY ON RATHER 2516 01:45:47,280 --> 01:45:48,640 THAN LATER. 2517 01:45:48,640 --> 01:45:51,280 IN THE REAL WORLD IT IS HARD TO 2518 01:45:51,280 --> 01:45:51,880 KNOW. 2519 01:45:51,880 --> 01:45:54,000 PATIENTS COME TO US AT DIFFERENT 2520 01:45:54,000 --> 01:45:57,400 TIMES AND WONDER IF WHEN DOING 2521 01:45:57,400 --> 01:45:59,120 CLINICAL TRIALS IS WORTHWHILE TO 2522 01:45:59,120 --> 01:46:01,000 SEPARATE THOSE THAT HAVE ACUTE 2523 01:46:01,000 --> 01:46:01,880 FROM CHRONIC PAIN. 2524 01:46:01,880 --> 01:46:04,080 WE KNOW WHEN THEY HAVE CHRONIC 2525 01:46:04,080 --> 01:46:07,040 PAIN THEY HAVE CHANGES IN 2526 01:46:07,040 --> 01:46:08,520 CENTRAL NERVOUS SYSTEM AND 2527 01:46:08,520 --> 01:46:10,240 SENSITIZATION AND MEMORY OF PAIN 2528 01:46:10,240 --> 01:46:12,560 GETS RE-ENFORCED. 2529 01:46:12,560 --> 01:46:14,680 PERHAPS THAT TIMING AND 2530 01:46:14,680 --> 01:46:15,960 MECHANISMS THAT ARE UNDERLYING 2531 01:46:15,960 --> 01:46:18,440 WHAT IS REALLY HAPPENING AT THE 2532 01:46:18,440 --> 01:46:22,360 TISSUE LEVEL THAT COULD ALSO 2533 01:46:22,360 --> 01:46:26,280 HELP US DETERMINE WHEN AND WHAT 2534 01:46:26,280 --> 01:46:27,840 INTERVENTION. 2535 01:46:27,840 --> 01:46:31,440 >>THANK YOU DR. RAGHAVAN AND 2536 01:46:31,440 --> 01:46:35,440 FOLLOW UP DISCUSSION IN Q & A I 2537 01:46:35,440 --> 01:46:39,760 SEE IN CHAT ABOUT LEVERAGING 2538 01:46:39,760 --> 01:46:40,400 PATHWAYS DISCUSSED YESTERDAY 2539 01:46:40,400 --> 01:46:42,200 SORT OF HOW TO DEVELOP 2540 01:46:42,200 --> 01:46:43,320 INTERVENTIONS TO TARGET THESE OR 2541 01:46:43,320 --> 01:46:47,120 DO WE HAVE TO UNDERSTAND THESE 2542 01:46:47,120 --> 01:46:48,320 BETTER TO TAILOR INTERVENTIONS 2543 01:46:48,320 --> 01:46:50,680 TO THIS AREA. I WOULD LIKE TO 2544 01:46:50,680 --> 01:46:52,720 CIRCLE BACK TO THAT A LITTLE BIT 2545 01:46:52,720 --> 01:46:55,640 LATER AND DR. BUTERA, YOU HAVE A 2546 01:46:55,640 --> 01:46:56,480 QUICK COMMENT? 2547 01:46:56,480 --> 01:46:59,080 >>YEAH. THANKS SO MUCH. I 2548 01:46:59,080 --> 01:47:02,320 WANTED TO PIGGYBACK OFF WHAT DR. 2549 01:47:02,320 --> 01:47:04,720 SLUKA WAS TALKING ABOUT GETTING 2550 01:47:04,720 --> 01:47:07,520 FUNDING TO DO THESE SORTS OF 2551 01:47:07,520 --> 01:47:09,800 TRIALS AND THINK THAT THIS IS 2552 01:47:09,800 --> 01:47:11,640 DEFINITELY SOMETHING THAT DR. 2553 01:47:11,640 --> 01:47:14,920 GOERTZ IS ALSO DOING AT DUKE AND 2554 01:47:14,920 --> 01:47:16,520 THINKING MORE ABOUT THIS 2555 01:47:16,520 --> 01:47:17,480 IMPLEMENTATION AND WE HAVE SO 2556 01:47:17,480 --> 01:47:19,280 MANY INTERVENTIONS. 2557 01:47:19,280 --> 01:47:21,320 AND, YOU KNOW, BUT THINKING 2558 01:47:21,320 --> 01:47:24,120 ABOUT WHEN DO WE APPLY THESE AND 2559 01:47:24,120 --> 01:47:26,200 IN WHAT ORDER AND WITH WHAT 2560 01:47:26,200 --> 01:47:26,600 DOSING. 2561 01:47:26,600 --> 01:47:29,160 SO, I THINK IT IS NOT JUST ABOUT 2562 01:47:29,160 --> 01:47:31,760 NEEDING FUNDING BUT ALSO 2563 01:47:31,760 --> 01:47:33,560 EXPERTISE AND EDUCATION FOR 2564 01:47:33,560 --> 01:47:36,600 RESEARCHERS THEMSELVES THAT 2565 01:47:36,600 --> 01:47:39,480 THERE IS IMPLEMENTATION TRIAL 2566 01:47:39,480 --> 01:47:43,400 DESIGNS AND THERE ARE SMART OR 2567 01:47:43,400 --> 01:47:46,120 ADAPTIVE TRIAL DESIGNS TO LOOK 2568 01:47:46,120 --> 01:47:47,960 AT ORDER OF INTERVENTIONS TO 2569 01:47:47,960 --> 01:47:51,080 MIMIC WHAT HAPPENS IN HEALTH 2570 01:47:51,080 --> 01:47:53,360 CARE SYSTEM AND NOT JUST ABOUT 2571 01:47:53,360 --> 01:47:55,640 GETTING FUNDING FOR LARGE TRIALS 2572 01:47:55,640 --> 01:47:56,440 AND HIGHLIGHTING IMPORTANCE 2573 01:47:56,440 --> 01:47:59,080 ACROSS RESEARCH COMMUNITY THAT 2574 01:47:59,080 --> 01:48:00,600 OFTEN TIMES WHEN WE START TO 2575 01:48:00,600 --> 01:48:03,840 TALK ABOUT IMPLEMENTATION 2576 01:48:03,840 --> 01:48:06,440 STUDIES WE GET PUSHBACK FROM 2577 01:48:06,440 --> 01:48:08,760 RESEARCHER WHO'S ARE TRADITIONAL 2578 01:48:08,760 --> 01:48:10,720 TRIALISTS SAY YOU CAN'T DO THIS 2579 01:48:10,720 --> 01:48:13,480 YOU ARE NOT CONTROLLING FOR THIS 2580 01:48:13,480 --> 01:48:14,000 OR THAT. 2581 01:48:14,000 --> 01:48:16,800 THAT IS KIND OF THE POINT AND 2582 01:48:16,800 --> 01:48:17,880 THINKING MORE ABOUT WHAT IS 2583 01:48:17,880 --> 01:48:20,480 NEEDED FOR IMPLEMENTATION AND 2584 01:48:20,480 --> 01:48:23,240 SURE THERE IS A LOT OF OTHER 2585 01:48:23,240 --> 01:48:25,000 PANELISTS WITH THOUGHTS ON THIS 2586 01:48:25,000 --> 01:48:27,000 AS WELL. 2587 01:48:27,000 --> 01:48:35,880 >>THANK YOU. DR. BOLIN? 2588 01:48:35,880 --> 01:48:39,520 >>THANK ENRICHING DISCUSSION 2589 01:48:39,520 --> 01:48:42,000 YESTERDAY AND TODAY. IDEAS 2590 01:48:42,000 --> 01:48:43,320 WHERE FIELD NEEDS TO GO AND WE 2591 01:48:43,320 --> 01:48:45,600 HAVE TO GO BIG OR GO HOME WHEN 2592 01:48:45,600 --> 01:48:47,840 IT COMES TO EXERCISING DOSING 2593 01:48:47,840 --> 01:48:49,400 TRIALS AND UNDERSTANDING 2594 01:48:49,400 --> 01:48:51,320 INDIVIDUAL DIFFERENCES AND HOW 2595 01:48:51,320 --> 01:48:53,400 THEY RESPOND IS A REALLY KEY 2596 01:48:53,400 --> 01:48:55,760 DIRECTION AND WOULD SAY THAT 2597 01:48:55,760 --> 01:48:57,480 WHAT I HEARD FROM THIS GROUP AND 2598 01:48:57,480 --> 01:49:01,120 HAVE SEEN AS A THEME THROUGHOUT 2599 01:49:01,120 --> 01:49:03,640 THIS IS, YOU KNOW, IF IT IS 2600 01:49:03,640 --> 01:49:05,880 EXERCISE, ANSWER REALLY IS 2601 01:49:05,880 --> 01:49:08,520 ALWAYS AND OFTEN. IT IS -- WHAT 2602 01:49:08,520 --> 01:49:10,520 IT BOILS DOWN TO, WE HAVE NO 2603 01:49:10,520 --> 01:49:12,240 EVIDENCE IT IS A NEGATIVE. 2604 01:49:12,240 --> 01:49:15,000 THE ISSUE BECOMES HOW DO WE DOSE 2605 01:49:15,000 --> 01:49:19,400 IT APPROPRIATELY FOR THE PERSON? 2606 01:49:19,400 --> 01:49:21,920 DOES IT REQUIRE COMBIN ATORIAL 2607 01:49:21,920 --> 01:49:24,400 TREATMENT TO GET THE INDIVIDUAL 2608 01:49:24,400 --> 01:49:25,440 TO RESPOND OPTIMALLY? 2609 01:49:25,440 --> 01:49:28,720 I THINK THERE IS A GREAT FUTURE 2610 01:49:28,720 --> 01:49:31,360 IF FOR COMBIN ATORIAL TREATMENT 2611 01:49:31,360 --> 01:49:33,120 TRIALS AND STARTING TO TEASE 2612 01:49:33,120 --> 01:49:35,320 APART FENOMIC AS WELL AS 2613 01:49:35,320 --> 01:49:38,320 MOLECULAR AND BIOLOGICAL INDICES 2614 01:49:38,320 --> 01:49:39,800 WHAT MAKES A PERSON RESPOND THAT 2615 01:49:39,800 --> 01:49:42,160 IS A KEY QUESTION THAT IS GOING 2616 01:49:42,160 --> 01:49:45,240 FORWARD AND THIS IDEA OF 2617 01:49:45,240 --> 01:49:45,880 MULTIMODALITY TREATMENT IS I 2618 01:49:45,880 --> 01:49:48,480 THINK WHERE WE HAVE TO GO AND 2619 01:49:48,480 --> 01:49:49,840 THAT DOES REQUIRE LARGE-SCALE 2620 01:49:49,840 --> 01:49:51,960 WORK FOR SURE. 2621 01:49:51,960 --> 01:49:55,640 >>THANK YOU DR. BAMMAN. 2622 01:49:55,640 --> 01:50:00,280 PICKING UP ON THAT KS. I 2623 01:50:00,280 --> 01:50:02,280 NOTICED IN THE CHAT QUESTIONS 2624 01:50:02,280 --> 01:50:07,920 FOR CHANGING ADIPOSE SECRETE OHM 2625 01:50:07,920 --> 01:50:10,080 OR TRANSCRIPT OHM OF FAT IN 2626 01:50:10,080 --> 01:50:13,320 JOINT AND PERIPHERAL MILIEU OR 2627 01:50:13,320 --> 01:50:15,680 CYTOKINE MAKEUP OR MORE GENERAL 2628 01:50:15,680 --> 01:50:18,240 OR BIOMEDICAL OR REDUCTION IN 2629 01:50:18,240 --> 01:50:20,800 WEIGHT AND WOULD LOVE TO HEAR 2630 01:50:20,800 --> 01:50:22,800 PANELS WAYS TO INTEGRATE 2631 01:50:22,800 --> 01:50:24,280 BIOLOGICAL MECHANISMS DISCUSSED 2632 01:50:24,280 --> 01:50:26,000 YESTERDAY WITH ONGOING TRIALS 2633 01:50:26,000 --> 01:50:27,240 AND INTERVENTIONS AND ARE THERE 2634 01:50:27,240 --> 01:50:30,440 OTHER AREAS THAT WE CAN EXPLORE 2635 01:50:30,440 --> 01:50:34,160 LIKE THAT EXAMPLE THAT DR. 2636 01:50:34,160 --> 01:50:36,600 WILLIAMS AND DR. KELSEY DID A 2637 01:50:36,600 --> 01:50:38,520 FOLLOW-UP QUESTION AND DO WE 2638 01:50:38,520 --> 01:50:39,960 KNOW ANYTHING ABOUT SECRETE OHM 2639 01:50:39,960 --> 01:50:41,720 IN THAT IT IS SOMETHING THAT IS 2640 01:50:41,720 --> 01:50:45,280 SPECIFIC HAPPENING IN THE AREA 2641 01:50:45,280 --> 01:50:46,760 OF THE JOINT? 2642 01:50:46,760 --> 01:50:49,400 ARE THERE OTHER THOUGHTS ABOUT 2643 01:50:49,400 --> 01:50:51,840 WAYS TO INCORPORATE TOPICS THAT 2644 01:50:51,840 --> 01:50:53,040 WERE DISCUSSED YESTERDAY? 2645 01:50:53,040 --> 01:50:55,840 DR. SLUKA? 2646 01:50:55,840 --> 01:50:57,320 >>I'M A STRONG BELIEVER WE NEED 2647 01:50:57,320 --> 01:51:01,120 TO KNOW WHAT INTERVENTIONS ARE 2648 01:51:01,120 --> 01:51:02,960 DOING TO BEST APPLY THEM. IF WE 2649 01:51:02,960 --> 01:51:07,320 CAN'T JUST APPLY THEM IN A BLACK 2650 01:51:07,320 --> 01:51:11,040 BOX AND SAY THIS WORKS SO WE DO 2651 01:51:11,040 --> 01:51:11,200 IT. 2652 01:51:11,200 --> 01:51:12,600 REASON I SPENT 20 YEARS OR 10 OR 2653 01:51:12,600 --> 01:51:15,360 15 YEARS TRYING TO FIGURE OUT 2654 01:51:15,360 --> 01:51:17,960 HOW IT WORKS IS IMPROVING 2655 01:51:17,960 --> 01:51:22,880 EFFICACY AND IN THE CLINIC AND 2656 01:51:22,880 --> 01:51:27,720 SIMILAR FOR EXERCISE IT CHANGES 2657 01:51:27,720 --> 01:51:30,200 -- EXERCISE CHANGES PERIPHERAL 2658 01:51:30,200 --> 01:51:31,080 NERVOUS SYSTEM AND DOES ALL OF 2659 01:51:31,080 --> 01:51:34,240 THE ABOVE AND IS A WONDERFUL 2660 01:51:34,240 --> 01:51:35,360 MULTIMODAL TREATMENT WORKING 2661 01:51:35,360 --> 01:51:37,360 WITH A NUMBER OF DIFFERENT 2662 01:51:37,360 --> 01:51:38,240 MECHANISMS TRANSLATING THEM BACK 2663 01:51:38,240 --> 01:51:40,080 INTO HUMAN STUDIES MAKING SURE 2664 01:51:40,080 --> 01:51:41,880 WE ARE SEEING SIMILAR THINGS 2665 01:51:41,880 --> 01:51:43,680 WOULD BE WONDERFUL. WE NEED 2666 01:51:43,680 --> 01:51:46,480 PEOPLE WHO LOOK AT MECHANISMS IN 2667 01:51:46,480 --> 01:51:48,240 CLINICAL TRIALS THEY ARE DOING 2668 01:51:48,240 --> 01:51:50,120 AS WELL AS MECHANISMS IN ANIMAL 2669 01:51:50,120 --> 01:51:52,920 WORK AND STUDIES TO SEE WHAT 2670 01:51:52,920 --> 01:51:54,880 EXERCISE IS DOING TO BETTER 2671 01:51:54,880 --> 01:51:58,440 INFORM HOW WE WOULD APPLY IT. 2672 01:51:58,440 --> 01:52:00,400 IS RESISTANCE TRAINING SAME AS 2673 01:52:00,400 --> 01:52:03,600 AEROBIC TRAINING AND STRETCHING 2674 01:52:03,600 --> 01:52:07,440 OF MYOFASCIAL TECHNIQUES THE 2675 01:52:07,440 --> 01:52:08,840 SAME AND WHAT IS MANUAL THERAPY 2676 01:52:08,840 --> 01:52:11,160 DOING AND IS THAT SUPER 2677 01:52:11,160 --> 01:52:12,600 IMPORTANT TO BETTER USE 2678 01:52:12,600 --> 01:52:13,920 INTERVENTIONS TO KNOW HOW TO DO 2679 01:52:13,920 --> 01:52:15,880 IT AND WE KNOW HOW 2680 01:52:15,880 --> 01:52:16,800 PHARMACEUTICAL INTERVENTIONS 2681 01:52:16,800 --> 01:52:19,480 WORK AND ARE APPLIED BASED ON 2682 01:52:19,480 --> 01:52:22,040 UNDERLYING MECHANISTIC 2683 01:52:22,040 --> 01:52:24,200 HYPOTHESIS AND WE DON'T APPLY 2684 01:52:24,200 --> 01:52:25,720 YOU KNOW ANTIDEPRESSANTS TO 2685 01:52:25,720 --> 01:52:28,920 PEOPLE AND I WILL TALK ABOUT 2686 01:52:28,920 --> 01:52:30,600 DEPRESSION AND ANXIETY NOT ABOUT 2687 01:52:30,600 --> 01:52:34,840 PAIN RIGHT NOW AND WE DON'T HAVE 2688 01:52:34,840 --> 01:52:35,560 ANTIDEPRESSANTS TO PEOPLE THAT 2689 01:52:35,560 --> 01:52:37,240 ARE NOT DEPRESSED UNLESS FOR 2690 01:52:37,240 --> 01:52:38,880 PAIN AND THEY HAVE TO HAVE 2691 01:52:38,880 --> 01:52:41,200 CENTRAL MECHANISMS FOR THAT. WE 2692 01:52:41,200 --> 01:52:43,560 NEED SAME THOUGHT PROCESS WHEN 2693 01:52:43,560 --> 01:52:45,360 WE START TO APPLY NON-DRUG 2694 01:52:45,360 --> 01:52:46,480 TREATMENTS AND WILL LEAVE IT AT 2695 01:52:46,480 --> 01:52:46,720 THAT. 2696 01:52:46,720 --> 01:52:49,680 >>I TOTALLY AGREE. YOU KNOW, 2697 01:52:49,680 --> 01:52:51,560 SINCE YOU KNOW YOU BROUGHT UP 2698 01:52:51,560 --> 01:52:52,760 THIS IDEA OF COMPARING 2699 01:52:52,760 --> 01:52:56,880 TREATMENTS OR INTERVENTIONS TO 2700 01:52:56,880 --> 01:52:58,440 SMALL MOLECULES AND HOW THEY ARE 2701 01:52:58,440 --> 01:53:01,160 DEVELOPED AND YOU MENTIONED 2702 01:53:01,160 --> 01:53:01,800 DURING YOUR TALK. 2703 01:53:01,800 --> 01:53:05,720 YOU MENTIONED THAT THE TIMING 2704 01:53:05,720 --> 01:53:08,560 AND USING THE RIGHT DOSE OF TENS 2705 01:53:08,560 --> 01:53:11,280 OR ELECT TROE SUIT CALS FOR LACK 2706 01:53:11,280 --> 01:53:13,040 OF A BETTER TERM OVER THERE. 2707 01:53:13,040 --> 01:53:17,480 HAVE YOU LOOKED AT OR IS THERE A 2708 01:53:17,480 --> 01:53:23,000 GOOD WAY TO ASSESS WHETHER OR 2709 01:53:23,000 --> 01:53:24,840 NOT TARGET ENGAGEMENT OF 2710 01:53:24,840 --> 01:53:26,400 ELECTRICAL STIMULATION IS REALLY 2711 01:53:26,400 --> 01:53:29,160 HITTING THE NERVE WE WANT? AT, 2712 01:53:29,160 --> 01:53:30,880 YOU KNOW, AT THAT RIGHT DOSE AND 2713 01:53:30,880 --> 01:53:34,440 WITH THE RIGHT TIMING? 2714 01:53:34,440 --> 01:53:36,360 IF THAT IS -- YOU KNOW, IF IT 2715 01:53:36,360 --> 01:53:38,360 COULD REALLY HELP US DEFINE 2716 01:53:38,360 --> 01:53:40,200 WHETHER OR NOT INTERVENTION IS 2717 01:53:40,200 --> 01:53:41,840 APPROPRIATE FOR PATIENT. YOU 2718 01:53:41,840 --> 01:53:46,120 CAN IMAGINE IF YOU ARE USING A 2719 01:53:46,120 --> 01:53:46,960 NON-INVASIVE STIMULATION 2720 01:53:46,960 --> 01:53:49,120 TECHNIQUE AND PERSON HAS A BMI 2721 01:53:49,120 --> 01:53:51,040 OF 39 OR 40 IT WOULD BE 2722 01:53:51,040 --> 01:53:52,360 DIFFERENT THAN IF THE 2723 01:53:52,360 --> 01:53:54,200 INTERVENTION AND IF THEY HAD BMI 2724 01:53:54,200 --> 01:53:58,640 OF SAY 23. WHAT DO YOU THINK, 2725 01:53:58,640 --> 01:53:59,280 CATHERINE? 2726 01:53:59,280 --> 01:54:00,640 >>PERHAPS FROM A CLINICAL 2727 01:54:00,640 --> 01:54:03,120 PERSPECTIVE IT WOULD BE HARD TO 2728 01:54:03,120 --> 01:54:05,400 REALLY FIGURE THAT OUT. YES. 2729 01:54:05,400 --> 01:54:07,960 SUPPOSING YOU PUT ELECTRICAL 2730 01:54:07,960 --> 01:54:10,440 STIMULATION THROUGH THE SKIN 2731 01:54:10,440 --> 01:54:12,680 TALKING ABOUT STRONG 2732 01:54:12,680 --> 01:54:13,960 UNCOMFORTABLE INTENSITY YOU ARE 2733 01:54:13,960 --> 01:54:15,880 GETTING PAST THE SKIN AND TO 2734 01:54:15,880 --> 01:54:16,760 RIGHT TARGET [INDISCERNIBLE] AND 2735 01:54:16,760 --> 01:54:18,840 THERE ARE WAYS TO DO IT. WE DO 2736 01:54:18,840 --> 01:54:21,040 NEED -- THAT IS PART OF 2737 01:54:21,040 --> 01:54:22,120 APPROPRIATE DOSING AND WILL SAY 2738 01:54:22,120 --> 01:54:25,360 WE HAVE HAD RESPONDERS IN OUR 2739 01:54:25,360 --> 01:54:27,000 CLINICAL TRIALS WITH 2740 01:54:27,000 --> 01:54:29,960 FIBROMYALGIA WITH TENS WITH HIGH 2741 01:54:29,960 --> 01:54:32,640 BMIS AND STILL RESPONDED BECAUSE 2742 01:54:32,640 --> 01:54:35,280 WE GAVE IT AN AT AN ADEQUATE 2743 01:54:35,280 --> 01:54:37,280 DOSE AND THINK THAT IS PATIENT 2744 01:54:37,280 --> 01:54:37,640 SPECIFIC. 2745 01:54:37,640 --> 01:54:39,280 YES. WE NEED TO DO THAT AND 2746 01:54:39,280 --> 01:54:41,160 MAKE SURE WE ARE GIVING RIGHT 2747 01:54:41,160 --> 01:54:43,760 DOSE THAT ACTUALLY IS NOT BASED 2748 01:54:43,760 --> 01:54:46,560 ON NUMBER ON THE UNIT BUT RATHER 2749 01:54:46,560 --> 01:54:49,400 THE PERSON RESPONSE TO THAT 2750 01:54:49,400 --> 01:54:49,680 DOSE. 2751 01:54:49,680 --> 01:54:51,000 THAT IS TRUE FOR EVERYTHING WE 2752 01:54:51,000 --> 01:54:52,960 DO. WHAT IS THE DOSE? HOW IS 2753 01:54:52,960 --> 01:54:55,840 IT INDIVIDUALIZED TO THE PERSON 2754 01:54:55,840 --> 01:54:56,360 ITSELF? 2755 01:54:56,360 --> 01:54:58,640 >>PERFECT. MAKES SENSE. 2756 01:54:58,640 --> 01:55:01,760 FOLLOW-UP QUESTION TO THAT IS 2757 01:55:01,760 --> 01:55:06,960 FOR DR. ROHN IF MANUAL THERAPY 2758 01:55:06,960 --> 01:55:09,360 LIKE WE SAID EARLIER COULD BE 2759 01:55:09,360 --> 01:55:11,560 EXERCISE IN SOME WAY AND YOU 2760 01:55:11,560 --> 01:55:13,960 MENTIONED IN YOUR TALK THAT 2761 01:55:13,960 --> 01:55:15,360 LOADING OF THE JOINT IS 2762 01:55:15,360 --> 01:55:16,680 CORRECTLY SOMETHING TO LOOK AT 2763 01:55:16,680 --> 01:55:18,160 MONITORING THE PATIENT. COULD 2764 01:55:18,160 --> 01:55:20,560 IT BE THAT MONITORING THE 2765 01:55:20,560 --> 01:55:23,160 SENSORY FEEDBACK AND REALLY 2766 01:55:23,160 --> 01:55:25,840 ELECT TROE PHYSIOLOGICAL CENSOR 2767 01:55:25,840 --> 01:55:28,120 OF THE SENSORY NERVE COULD HELP 2768 01:55:28,120 --> 01:55:30,680 US IN THESE ELECTROTHERAPIES OR 2769 01:55:30,680 --> 01:55:34,280 YOU KNOW INTERVENTIONS TO TRY TO 2770 01:55:34,280 --> 01:55:36,480 REPRODUCE A CORRECT SENSORY 2771 01:55:36,480 --> 01:55:38,960 FEEDBACK TO THIS CNS FROM THAT 2772 01:55:38,960 --> 01:55:39,240 JOINT? 2773 01:55:39,240 --> 01:55:40,840 >>YEAH. THIS IS A GOOD 2774 01:55:40,840 --> 01:55:42,560 QUESTION. I THINK THERE IS A 2775 01:55:42,560 --> 01:55:48,680 LOT ABOUT THE SPECIFIC M 2776 01:55:48,680 --> 01:55:50,440 MECHANISMS OF MANUAL THERAPY WE 2777 01:55:50,440 --> 01:55:51,760 DON'T UNDERSTAND AND EXPLORING 2778 01:55:51,760 --> 01:55:53,040 THERE TO BETTER UNDERSTAND 2779 01:55:53,040 --> 01:55:57,120 DOSING OR TAILORING OF THE 2780 01:55:57,120 --> 01:56:01,040 LOADING AND INDIVIDUALIZED 2781 01:56:01,040 --> 01:56:03,960 RESPONSES AND HOW THEY VARY. 2782 01:56:03,960 --> 01:56:07,480 MAYBE THESE TAILORED TREATMENTS 2783 01:56:07,480 --> 01:56:09,400 IF WE CAN UNDERSTAND THAT 2784 01:56:09,400 --> 01:56:14,000 INTERACTION BETTER I THINK THAT 2785 01:56:14,000 --> 01:56:15,480 VERY PLAUSIBLE HYPOTHESIS TO 2786 01:56:15,480 --> 01:56:17,120 BETTER UNDERSTAND THAT MAYBE WE 2787 01:56:17,120 --> 01:56:19,680 CAN UNDERSTAND DOSING AND HOW WE 2788 01:56:19,680 --> 01:56:22,120 INTERVENE AND CAN TAILOR THAT 2789 01:56:22,120 --> 01:56:24,640 FOR PATIENTS A LITTLE BETTER AND 2790 01:56:24,640 --> 01:56:27,000 YEAH. I THINK THERE IS A LOT 2791 01:56:27,000 --> 01:56:31,080 THERE THAT IS STILL UNTAPPED. 2792 01:56:31,080 --> 01:56:32,160 >>EXCELLENT. THANKS. 2793 01:56:32,160 --> 01:56:34,520 >>YOU KNOW, IT IS A FOLLOW UP 2794 01:56:34,520 --> 01:56:37,000 TO THAT TO UNDERSTAND WHAT IS 2795 01:56:37,000 --> 01:56:38,240 THIS FEEDBACK THAT IS HAPPENING 2796 01:56:38,240 --> 01:56:42,000 FROM THE PERIPHERY TO THE CNS 2797 01:56:42,000 --> 01:56:44,000 THAT LEADS PERCEPTION OF PAIN OR 2798 01:56:44,000 --> 01:56:46,920 CHANGE IN PERCEPTION OF THE 2799 01:56:46,920 --> 01:56:50,000 JOINTS AND THIS QUESTION IS FOR 2800 01:56:50,000 --> 01:56:55,960 DR. RAGHAVAN IF IT DISRUPTS 2801 01:56:55,960 --> 01:56:57,200 SPINDLE AND FEEDBACK FROM THE 2802 01:56:57,200 --> 01:56:59,160 SPINDLE COULD IT LEAD TO MORE 2803 01:56:59,160 --> 01:57:03,400 FALLS OR LACK OF, YOU KNOW, 2804 01:57:03,400 --> 01:57:05,520 APPRO RIO CREPTOR CONTROL OR 2805 01:57:05,520 --> 01:57:08,040 CHANGE OF DATE OF THOSE WITH 2806 01:57:08,040 --> 01:57:10,320 INCREASED LEVEL OF HIGH ALLURE 2807 01:57:10,320 --> 01:57:12,840 ONIC ACID IN MUSCLES AROUND THE 2808 01:57:12,840 --> 01:57:13,120 SPINDLE? 2809 01:57:13,120 --> 01:57:15,360 >>EXCELLENT QUESTION. 2810 01:57:15,360 --> 01:57:17,360 WE ANECDOTALLY WE ARE SEEING 2811 01:57:17,360 --> 01:57:18,760 THAT PATIENTS HAVE BETTER 2812 01:57:18,760 --> 01:57:23,200 SENSATION WHEN WE REMOVE THEIR 2813 01:57:23,200 --> 01:57:23,560 STIFFNESS. 2814 01:57:23,560 --> 01:57:26,360 WHEN WE REDUCE STIFFNESS WE SEE 2815 01:57:26,360 --> 01:57:28,880 THAT PATIENTS WHO MIGHT HAVE 2816 01:57:28,880 --> 01:57:30,360 POOR BALANCE TO START WITH 2817 01:57:30,360 --> 01:57:33,840 BECAUSE OF NEUROLOGICAL DEFICITS 2818 01:57:33,840 --> 01:57:37,640 ARE ABLE TO MORE FLEXIBLY ALTER 2819 01:57:37,640 --> 01:57:39,440 THEIR STANCE WHEN THEY OR THERE 2820 01:57:39,440 --> 01:57:43,480 IS -- WHEN THEY MEET WITH A PER 2821 01:57:43,480 --> 01:57:46,600 TUR BASING AND WE ARE PART OF A 2822 01:57:46,600 --> 01:57:48,080 CLINICAL TRIAL WE ARE RUNNING WE 2823 01:57:48,080 --> 01:57:53,080 WILL LOOK AT CHANGES IN 2824 01:57:53,080 --> 01:57:53,840 PROPRIOCEPTION AS WELL AND THINK 2825 01:57:53,840 --> 01:57:55,640 THAT BECAUSE OF THE LOCATION OF 2826 01:57:55,640 --> 01:57:57,880 THE SPINDLE RECEPTORS AND NERVES 2827 01:57:57,880 --> 01:58:00,000 THAT ENTER MUSCLE WITHIN THE 2828 01:58:00,000 --> 01:58:02,960 MUSCLE WE THINK THAT, YOU KNOW, 2829 01:58:02,960 --> 01:58:07,160 ALTERATIONS IN STIFFNESS OF THE 2830 01:58:07,160 --> 01:58:12,480 TISSUE CAN CHANGE YOUR -- CAN 2831 01:58:12,480 --> 01:58:14,520 ACTUALLY IMPINGE ON SYMPATHETICS 2832 01:58:14,520 --> 01:58:16,680 RUNNING WITH VASCULAR AND 2833 01:58:16,680 --> 01:58:19,240 IMPINGE ON STRETCH RECEPTORS AND 2834 01:58:19,240 --> 01:58:21,680 MECHANICAL LOADING OF JOINTS. 2835 01:58:21,680 --> 01:58:23,200 MUSCLES ARE STUCK TOGETHER. YOU 2836 01:58:23,200 --> 01:58:25,320 TRY TO GENERATE FORCES THAT WILL 2837 01:58:25,320 --> 01:58:26,920 CHANGE LOADING ON JOINTS. 2838 01:58:26,920 --> 01:58:30,880 SO, YOU KNOW, THERE IS MANY 2839 01:58:30,880 --> 01:58:32,080 POTENTIAL WAYS THAT THIS COULD 2840 01:58:32,080 --> 01:58:34,600 EXPLAIN SOME OF WHAT WE ARE 2841 01:58:34,600 --> 01:58:34,840 SEEING. 2842 01:58:34,840 --> 01:58:39,400 >>EXCELLENT. THANKS SO MU. 2843 01:58:39,400 --> 01:58:42,640 THIS IS A QUESTION FOR DR. 2844 01:58:42,640 --> 01:58:42,920 MESSIER. 2845 01:58:42,920 --> 01:58:45,120 WE MENTIONED THIS IDEA OF WEIGHT 2846 01:58:45,120 --> 01:58:48,160 AND DIET AS, YOU KNOW, 2847 01:58:48,160 --> 01:58:50,000 INTERRELATED IN SOME WAY THAT 2848 01:58:50,000 --> 01:58:52,080 COULD INFLUENCE PAIN OUTCOMES 2849 01:58:52,080 --> 01:58:53,200 DEPENDING ON THE JOINT. 2850 01:58:53,200 --> 01:58:55,640 SO, YOU KNOW, DOES AN 2851 01:58:55,640 --> 01:58:57,080 INFLAMMATORY DIET, COULD THAT 2852 01:58:57,080 --> 01:58:58,880 MAKE A DIFFERENCE? 2853 01:58:58,880 --> 01:59:01,400 ISN'T IT SPECIFIC ASPECTS OF THE 2854 01:59:01,400 --> 01:59:04,280 DIET, MEANING NOT JUST 2855 01:59:04,280 --> 01:59:05,520 INFLAMMATORY OR INFLAMMATORY 2856 01:59:05,520 --> 01:59:08,000 DIET IN GENERAL BUT MAYBE 2857 01:59:08,000 --> 01:59:10,600 SPECIFIC LIPID MEDIATORS THAT 2858 01:59:10,600 --> 01:59:12,840 CHRIS WHO IS AN INTRAMURAL 2859 01:59:12,840 --> 01:59:15,200 RESEARCHER AT NIH HAS SHOWN 2860 01:59:15,200 --> 01:59:17,400 DECREASED INFLAMMATION IN THE 2861 01:59:17,400 --> 01:59:18,480 JOINTS AND MUSCLES AND IS THAT 2862 01:59:18,480 --> 01:59:21,360 GOAL HERE WITH THE DIET OR JUST 2863 01:59:21,360 --> 01:59:24,440 DECREASING CALORIES AND ADIPOSE 2864 01:59:24,440 --> 01:59:26,040 TISSUE IN THE JOINT? WHAT IS 2865 01:59:26,040 --> 01:59:26,720 THE GOAL HERE? 2866 01:59:26,720 --> 01:59:28,600 >>FOR US, THE LATTER. 2867 01:59:28,600 --> 01:59:30,960 THERE ARE TWO PATHWAYS THAT I 2868 01:59:30,960 --> 01:59:33,400 THINK I SHOWED THAT AS 2869 01:59:33,400 --> 01:59:34,400 BIOMECHANICAL PATHWAY THAT IS 2870 01:59:34,400 --> 01:59:36,800 THE LOAD. YOU DECREASE WEIGHT 2871 01:59:36,800 --> 01:59:37,640 AND LOAD. 2872 01:59:37,640 --> 01:59:39,080 WHILE YOU ARE DECREASING THE 2873 01:59:39,080 --> 01:59:41,760 WEIGHT YOU ARE DECREASING 2874 01:59:41,760 --> 01:59:47,720 ADIPOSE TISSUE AND DECREASING 2875 01:59:47,720 --> 01:59:49,400 INFLAMMATORY CYTOKINES AS WELL. 2876 01:59:49,400 --> 01:59:53,360 SO, WE GET WHAT WEIGHT LOSS DOES 2877 01:59:53,360 --> 01:59:56,640 IS IT IMPACTS BOTH INFLAMMATORY 2878 01:59:56,640 --> 02:00:00,000 -- BOTH OF THE PATHWAYS, 2879 02:00:00,000 --> 02:00:04,160 BIOMECHANICAL AND INFLAMMATORY. 2880 02:00:04,160 --> 02:00:06,680 WE DO A BALANCED DIET AND EAT 2881 02:00:06,680 --> 02:00:09,840 FEWER CALORIES. 2882 02:00:09,840 --> 02:00:14,040 AND ADDING EXERCISE HELPS YOU 2883 02:00:14,040 --> 02:00:15,120 MAINTAIN WEIGHT LOSS. 2884 02:00:15,120 --> 02:00:16,200 THOSE ARE TWO THINGS. 2885 02:00:16,200 --> 02:00:18,920 YOU KNOW, THE OTHER THING I WILL 2886 02:00:18,920 --> 02:00:21,280 SAY ABOUT THE EXERCISE AND I'M 2887 02:00:21,280 --> 02:00:22,920 IN DEPARTMENT OF HEALTH AND 2888 02:00:22,920 --> 02:00:24,200 EXERCISE SCIENCE. IT IS HARD 2889 02:00:24,200 --> 02:00:28,880 FOR ME TO COME OUT AND SAY 2890 02:00:28,880 --> 02:00:31,080 EXERCISE HAS A LIMITED EFFECT ON 2891 02:00:31,080 --> 02:00:32,840 PAIN IN THIS POPULATION. I 2892 02:00:32,840 --> 02:00:34,680 THINK IT DOES HAVE A VERY LIMIT 2893 02:00:34,680 --> 02:00:36,400 -- THAT IS NOT TO SAY WHAT I 2894 02:00:36,400 --> 02:00:39,840 WANT OUR PATIENTS TO EXERCISE. 2895 02:00:39,840 --> 02:00:40,120 ABSOLUTELY. 2896 02:00:40,120 --> 02:00:44,200 THEY WILL GET 25 TO 35% 2897 02:00:44,200 --> 02:00:46,520 REDUCTION IN PAIN AND SO WILL 2898 02:00:46,520 --> 02:00:48,360 PAYING ATTENTION TO PEOPLE IN 2899 02:00:48,360 --> 02:00:49,000 OTHER WAYS. 2900 02:00:49,000 --> 02:00:52,520 WHAT WE WANT TO DO IS GET BEYOND 2901 02:00:52,520 --> 02:00:55,880 THAT 25 OR 35% REDUCTION IN 2902 02:00:55,880 --> 02:00:59,680 PAIN. 50%. 75% TO REALLY SEE A 2903 02:00:59,680 --> 02:01:00,000 DIFFERENCE. 2904 02:01:00,000 --> 02:01:01,520 THE BIGGEST DIFFERENCE THAT WE 2905 02:01:01,520 --> 02:01:04,800 HAVE SEEN IS THE WEIGHT LOSS. 2906 02:01:04,800 --> 02:01:07,400 THAT IS -- IT HAS THE BIGGEST 2907 02:01:07,400 --> 02:01:10,760 IMPACT WE HAVE SEEN FROM A 2908 02:01:10,760 --> 02:01:12,240 NONPHARMACOLOGIC POINT OF VIEW. 2909 02:01:12,240 --> 02:01:14,800 THAT IS NOT TO SAY THAT IT 2910 02:01:14,800 --> 02:01:15,920 DEPENDS WHAT YOUR OUTCOME 2911 02:01:15,920 --> 02:01:18,040 MEASURE IS; RIGHT? 2912 02:01:18,040 --> 02:01:19,840 PATIENTS, WHAT THEY CARE ABOUT 2913 02:01:19,840 --> 02:01:20,120 IS PAIN. 2914 02:01:20,120 --> 02:01:20,960 >>OF COURSE. 2915 02:01:20,960 --> 02:01:21,760 >>RIGHT? 2916 02:01:21,760 --> 02:01:24,240 FROM A PAIN PERSPECTIVE, IT 2917 02:01:24,240 --> 02:01:25,560 DOESN'T MATTER FROM WHAT -- FROM 2918 02:01:25,560 --> 02:01:27,400 OUR EXPERIENCE THAT WE HAVE BEEN 2919 02:01:27,400 --> 02:01:30,480 DOING CLINICAL TRIALS FOR OVER 2920 02:01:30,480 --> 02:01:32,080 30 YEARS. 2921 02:01:32,080 --> 02:01:33,680 IT DOESN'T MATTER WHAT KIND OF 2922 02:01:33,680 --> 02:01:34,080 EXERCISE. 2923 02:01:34,080 --> 02:01:36,680 YOU WILL GET SAME RESULT, ABOUT 2924 02:01:36,680 --> 02:01:39,760 35% REDUCTION PAIN. CONTROL 2925 02:01:39,760 --> 02:01:41,400 GROUPS PAYING ATTENTION TO THEM, 2926 02:01:41,400 --> 02:01:44,040 YOU GET 33% REDUCTION IN PAIN. 2927 02:01:44,040 --> 02:01:45,120 ALL RIGHT? 2928 02:01:45,120 --> 02:01:46,040 >>RIGHT. 2929 02:01:46,040 --> 02:01:48,080 >>ONLY THING THAT TAKES YOU 2930 02:01:48,080 --> 02:01:50,400 ABOVE THAT IS WHAT -- ADDING 2931 02:01:50,400 --> 02:01:52,280 WEIGHT LOSS TO IT AND HOW MUCH 2932 02:01:52,280 --> 02:01:54,360 WEIGHT LOSS MAKES A DIFFERENCE 2933 02:01:54,360 --> 02:01:56,760 AND 5% WEIGHT LOSS IS GREAT AND 2934 02:01:56,760 --> 02:01:59,160 10% IS ACTUALLY TWICE AS GOOD 2935 02:01:59,160 --> 02:02:01,960 AND 20% IS NOT TWICE AS GOOD AS 2936 02:02:01,960 --> 02:02:07,080 10% BUT IT IS -- IT IS BETTER. 2937 02:02:07,080 --> 02:02:10,040 SO, THAT IS WHERE WE COME FROM. 2938 02:02:10,040 --> 02:02:12,160 AND I GUESS YOU COULD GO AHEAD 2939 02:02:12,160 --> 02:02:16,200 WITH THE DIETS AND LOOK AT HIGH 2940 02:02:16,200 --> 02:02:17,480 INFLAMMATORY PARTS OF DIET AND 2941 02:02:17,480 --> 02:02:18,440 TAKE THAT OUT. 2942 02:02:18,440 --> 02:02:20,400 BUT, I DON'T KNOW IF YOU WILL 2943 02:02:20,400 --> 02:02:22,720 GET THIS BIGGER IMPACT THAT WE 2944 02:02:22,720 --> 02:02:23,800 ARE TRYING TO GET. 2945 02:02:23,800 --> 02:02:25,120 >>GOT IT. 2946 02:02:25,120 --> 02:02:27,480 >>YOU HAVE SMALL INCREMENTAL 2947 02:02:27,480 --> 02:02:28,080 IMPACTS. 2948 02:02:28,080 --> 02:02:31,560 BUT, WE ARE TRYING TO GET HUGE 2949 02:02:31,560 --> 02:02:35,000 IMPACTS AND 50% AND 75%. 2950 02:02:35,000 --> 02:02:35,600 >>RIGHT. 2951 02:02:35,600 --> 02:02:36,440 >>AND ANYWAY. 2952 02:02:36,440 --> 02:02:39,920 >>SO, I JUST HAVE ONE QUESTION. 2953 02:02:39,920 --> 02:02:43,520 THIS IS REALLY FOR -- OH, YEAH. 2954 02:02:43,520 --> 02:02:46,560 YOU KNOW, DR. BAMMAN, PLEASE. 2955 02:02:46,560 --> 02:02:48,120 >>I DON'T WANT TO INTERRUPT 2956 02:02:48,120 --> 02:02:50,520 YOU. I CAN WAIT. GO AHEAD. 2957 02:02:50,520 --> 02:02:51,960 >>I HAVE A FINAL QUESTION HERE 2958 02:02:51,960 --> 02:02:54,400 THAT IS REALLY FOR THE WHOLE 2959 02:02:54,400 --> 02:02:54,640 GROUP. 2960 02:02:54,640 --> 02:02:59,000 DO THESE INTERVENTIONS, MANUAL 2961 02:02:59,000 --> 02:03:01,360 THERAPIES, EXERCISE AND WEIGHT 2962 02:03:01,360 --> 02:03:04,360 LOSS AND ELECTRICAL STIMULATION, 2963 02:03:04,360 --> 02:03:06,720 ALL THOSE PUT TOGETHER OR 2964 02:03:06,720 --> 02:03:09,360 INDIVIDUALLY DEPEND ON THE TYPE 2965 02:03:09,360 --> 02:03:13,040 OF PAIN NO SUSSEPTIVE AND 2966 02:03:13,040 --> 02:03:16,200 INFLAMMATORY AND NEUROPATHIC AND 2967 02:03:16,200 --> 02:03:18,040 CHRONIC PAIN OPOSED TO CUE PAIN 2968 02:03:18,040 --> 02:03:20,640 AND DO THEY HAVE TO BE ARE THESE 2969 02:03:20,640 --> 02:03:24,080 GENERAL INTERVENTIONS OR ARE 2970 02:03:24,080 --> 02:03:27,160 THEY SPECIFIC FOR THE TYPE OF 2971 02:03:27,160 --> 02:03:28,440 PAIN? 2972 02:03:28,440 --> 02:03:32,120 ANYBODY WANT TO GRAB THAT ONE? 2973 02:03:32,120 --> 02:03:35,520 IS IT TOO BROAD? DR. BAMMAN, 2974 02:03:35,520 --> 02:03:38,880 YOU CAN DO IT IF YOU WANT OR 2975 02:03:38,880 --> 02:03:39,600 KATHLEEN, FEEL FREE. 2976 02:03:39,600 --> 02:03:41,080 >>REALLY TOUGH ONE. 2977 02:03:41,080 --> 02:03:46,960 >>WASN'T MEANT TO BE TSTUMP PE. 2978 02:03:46,960 --> 02:03:50,040 >>YEAH. I WILL DEFER TO THE 2979 02:03:50,040 --> 02:03:52,320 PANELISTS IT WAS TO BE AS 2980 02:03:52,320 --> 02:03:55,400 SPECIFIC AND MECHANISTIC AND 2981 02:03:55,400 --> 02:03:56,400 TARGETED AS WE COULD GET. I 2982 02:03:56,400 --> 02:03:58,440 WOULD SAY THERE ARE PROBABLY 2983 02:03:58,440 --> 02:04:00,720 DIFFERENT MECHANISMS AND 2984 02:04:00,720 --> 02:04:01,440 THEREFORE INTERVENTIONS HAVE TO 2985 02:04:01,440 --> 02:04:03,480 BE TARGETED IN DIFFERENT WAYS 2986 02:04:03,480 --> 02:04:04,800 WOULD BE MY GENERAL COMMENT ON 2987 02:04:04,800 --> 02:04:06,960 THAT AND WANTED TO MAKE A QUICK 2988 02:04:06,960 --> 02:04:08,480 COMMENT ABOUT AND HEARD OTHERS 2989 02:04:08,480 --> 02:04:10,120 BRING THIS ISSUE UP. 2990 02:04:10,120 --> 02:04:12,360 IN ANY FORM OF INTERVENTION 2991 02:04:12,360 --> 02:04:15,920 TRIAL, WE ALL ARE CHALLENGED BY 2992 02:04:15,920 --> 02:04:17,360 WHAT IS THE CONTROL. 2993 02:04:17,360 --> 02:04:19,040 GOING FORWARD, I THINK WE NEED 2994 02:04:19,040 --> 02:04:21,240 TO THINK CAREFULLY ABOUT HOW 2995 02:04:21,240 --> 02:04:22,800 BEST WE DEFINE THAT GROUP. 2996 02:04:22,800 --> 02:04:26,200 IN THIS CONTEXT, YOU KNOW, WE 2997 02:04:26,200 --> 02:04:29,240 DID A TRIAL WHERE WE RANDOMIZED 2998 02:04:29,240 --> 02:04:32,120 PEOPLE AFTER TOTAL JOINT 2999 02:04:32,120 --> 02:04:33,840 ARTHROMRAFTY TO INTERVENTION 3000 02:04:33,840 --> 02:04:36,640 VERSUS USUAL CARE AND HAD TO 3001 02:04:36,640 --> 02:04:38,200 DEFINE CONTROL GROUP AS USUAL 3002 02:04:38,200 --> 02:04:39,840 CARE. THERE IS A WIDE RANGE IN 3003 02:04:39,840 --> 02:04:42,880 WHAT THEY ACTUALLY EXPERIENCED. 3004 02:04:42,880 --> 02:04:45,280 YOU KNOW, SOME HAVE RIGOROUS 3005 02:04:45,280 --> 02:04:48,040 PHYSICAL THERAPY FOR 6 WEEKS 3006 02:04:48,040 --> 02:04:50,200 POST-OP AND SOME HAVE NONE AND 3007 02:04:50,200 --> 02:04:52,000 TWO WEEKS OF MODERATE THERAPY 3008 02:04:52,000 --> 02:04:54,280 AND IS A HUGE RANGE AND 3009 02:04:54,280 --> 02:04:55,480 THEREFORE THERE IS NO STANDARD 3010 02:04:55,480 --> 02:04:58,280 OF CARE AND HAD TO CALL IT USUAL 3011 02:04:58,280 --> 02:05:01,360 CARE AND CARE FROM SPEAKERS AND 3012 02:05:01,360 --> 02:05:02,680 PREOPERATIVELY AND PRIOR TO THE 3013 02:05:02,680 --> 02:05:06,840 END STAGE DISEASE ONLY 10 TO 15% 3014 02:05:06,840 --> 02:05:08,320 GET REFERRED FOR PHYSICAL 3015 02:05:08,320 --> 02:05:08,760 THERAPY. 3016 02:05:08,760 --> 02:05:12,120 ON PREOPERATIVE SIDE EARLIER IN 3017 02:05:12,120 --> 02:05:14,240 THE DISEASE PROGRESSION YOU 3018 02:05:14,240 --> 02:05:15,840 STILL HAVE A WIDE RANGE WHAT YOU 3019 02:05:15,840 --> 02:05:17,960 MIGHT TRY TO TAP INTO AS A 3020 02:05:17,960 --> 02:05:18,760 CONTROL CONDITION. 3021 02:05:18,760 --> 02:05:20,840 I THINK WE HAVE TO THINK 3022 02:05:20,840 --> 02:05:22,680 CAREFULLY ABOUT HOW DO WE 3023 02:05:22,680 --> 02:05:25,840 QUANTIFY A GROUP OF PEOPLE WHO 3024 02:05:25,840 --> 02:05:27,640 ARE NOT IN THE INTERVENTION FOR 3025 02:05:27,640 --> 02:05:29,000 ANY OF THESE TRIALS. 3026 02:05:29,000 --> 02:05:31,440 AND HOW BEST CAN WE COMPARE 3027 02:05:31,440 --> 02:05:33,400 THEM? YOU KNOW, WE NEED TO 3028 02:05:33,400 --> 02:05:35,080 PROBABLY DO A BETTER JOB WITH 3029 02:05:35,080 --> 02:05:36,440 WEARABLE TECHNOLOGIES AND NEED 3030 02:05:36,440 --> 02:05:38,680 TO DO A BETTER JOB WITH OTHER 3031 02:05:38,680 --> 02:05:41,360 MEANS OF MONITORING WHAT PEOPLE 3032 02:05:41,360 --> 02:05:44,000 ARE ACTUALLY DOING AND DATA GETS 3033 02:05:44,000 --> 02:05:46,240 PRETTY SLOPPY WHEN TRYING TO GET 3034 02:05:46,240 --> 02:05:47,760 A RIGOROUS INTERVENTION TRIAL 3035 02:05:47,760 --> 02:05:50,080 THAT YOU HAVE ESSENTIALLY NO 3036 02:05:50,080 --> 02:05:51,440 CONTROL OVER THIS OTHER GROUP OF 3037 02:05:51,440 --> 02:05:53,080 PEOPLE YOU WANT TO COMPARE IT TO 3038 02:05:53,080 --> 02:05:54,600 AND JUST TO MAKE THAT COMMENT 3039 02:05:54,600 --> 02:05:56,200 AND WE HAVE TO THINK ABOUT IT AS 3040 02:05:56,200 --> 02:05:58,560 A GROUP WHEN WE WANT TO GO LARGE 3041 02:05:58,560 --> 02:05:59,200 SCALE. 3042 02:05:59,200 --> 02:06:00,840 >>I LIKE THE WEARABLE 3043 02:06:00,840 --> 02:06:01,600 TECHNOLOGIES OVER THERE AND 3044 02:06:01,600 --> 02:06:03,760 FIGURING OUT A WAY TO DEAL WITH 3045 02:06:03,760 --> 02:06:05,840 LARGE AMOUNTS OF DATA WE WILL 3046 02:06:05,840 --> 02:06:08,280 HAVE THERE ALSO FROM MANY 3047 02:06:08,280 --> 02:06:10,720 PATIENTS THAT WE NEED IN TRIALS 3048 02:06:10,720 --> 02:06:12,480 TO DIFFERENTIATE. 3049 02:06:12,480 --> 02:06:13,080 THANKS SO MUCH. 3050 02:06:13,080 --> 02:06:15,120 DR. SLUKA? 3051 02:06:15,120 --> 02:06:18,120 >>I WILL GO BACK AND ANSWER 3052 02:06:18,120 --> 02:06:19,240 YOUR MECHANISM QUESTION AND 3053 02:06:19,240 --> 02:06:21,320 QUESTION IS DO WE NEED TO KNOW 3054 02:06:21,320 --> 02:06:23,600 MECHANISM -- DOES IT MATTER WHAT 3055 02:06:23,600 --> 02:06:29,200 MECHANISM PATIENT HAS AND 3056 02:06:29,200 --> 02:06:31,240 NOSICEPTIVE AND PLASTIC PAIN AND 3057 02:06:31,240 --> 02:06:33,200 TO SOME EXTENT YES AND LEARNING 3058 02:06:33,200 --> 02:06:35,080 ABOUT HOW INTERVENTIONS WORK IT 3059 02:06:35,080 --> 02:06:37,760 MAY BE LESS. EXERCISE CAN 3060 02:06:37,760 --> 02:06:40,520 PROMOTE HEALER OF PERIPHERAL 3061 02:06:40,520 --> 02:06:44,280 NERVES OF NEUROPATHIC PAIN AND 3062 02:06:44,280 --> 02:06:48,320 CHANGE CAPS YUM CHANNELS AND 3063 02:06:48,320 --> 02:06:53,360 REDUCE CAPS YUM AND SODIUM 3064 02:06:53,360 --> 02:06:55,720 CHANNELS CHANGING FROM 3065 02:06:55,720 --> 02:06:57,480 INFLAMMATORY TO ANTIINFLAMMATORY 3066 02:06:57,480 --> 02:06:59,640 STATE IN JOINT LEVEL AND IN 3067 02:06:59,640 --> 02:07:01,600 MUSCLE AND SYSTEMICALLY AND ON 3068 02:07:01,600 --> 02:07:07,480 CENTRAL NERVOUS SYSTEM IN GLIA 3069 02:07:07,480 --> 02:07:08,640 AND REDUCE CENTRAL 3070 02:07:08,640 --> 02:07:10,600 [INDISCERNIBLE] AND REDUCE 3071 02:07:10,600 --> 02:07:11,640 CENTRAL INHIBITION AND CHANGES 3072 02:07:11,640 --> 02:07:13,360 FUNCTION. WE ALL KNOW THAT. 3073 02:07:13,360 --> 02:07:16,000 IT WORKS ACROSS MULTIPLE 3074 02:07:16,000 --> 02:07:16,320 MECHANISMS. 3075 02:07:16,320 --> 02:07:18,280 MANUAL THERAPY IS SIMILARLY 3076 02:07:18,280 --> 02:07:19,480 DOING THAT. 3077 02:07:19,480 --> 02:07:23,000 KNOWING HOW OUR TREATMENTS WORK. 3078 02:07:23,000 --> 02:07:24,920 WHAT MECHANISMS THEY ARE AT 3079 02:07:24,920 --> 02:07:25,320 HELPS US. 3080 02:07:25,320 --> 02:07:30,280 DR. MESSIER SAID INDEED IT 3081 02:07:30,280 --> 02:07:32,280 DIDN'T MATTER WHAT EXERCISE THEY 3082 02:07:32,280 --> 02:07:33,840 USE THEY ALL SEEM TO WORK 3083 02:07:33,840 --> 02:07:35,600 EQUALLY WELL AND AGREE WITH 3084 02:07:35,600 --> 02:07:38,320 THAT. WE ARE WORKING ACROSS 3085 02:07:38,320 --> 02:07:39,920 MULTIPLE MECHANISMS AND SAME IS 3086 02:07:39,920 --> 02:07:41,360 TRUE FOR LOOKING FOR OTHER 3087 02:07:41,360 --> 02:07:42,720 INTERVENTIONS UNDERSTANDING HOW 3088 02:07:42,720 --> 02:07:43,840 THEY WORK AND UNDERSTANDING WHAT 3089 02:07:43,840 --> 02:07:47,080 IS GOING ON WITH YOUR PATIENT 3090 02:07:47,080 --> 02:07:48,000 INDIVIDUALIZING THAT TREATMENT 3091 02:07:48,000 --> 02:07:49,320 AND PICKING THEM APPROPRIATELY 3092 02:07:49,320 --> 02:07:51,440 MATTERS AND GOOD THING IS MANUAL 3093 02:07:51,440 --> 02:07:53,360 THERAPIES WORK ACROSS MULTIPLE 3094 02:07:53,360 --> 02:07:56,320 MECHANISMS AND ARE NOT A SINGLE 3095 02:07:56,320 --> 02:07:59,080 BUT MULTITARGET AND GREAT 3096 02:07:59,080 --> 02:07:59,720 MULTIMODAL TREATMENTS THAT IS 3097 02:07:59,720 --> 02:08:03,760 WHY THEY ARE WORKING ACROSS MORE 3098 02:08:03,760 --> 02:08:06,920 OR CROSS-EFFECTIVELY. 3099 02:08:06,920 --> 02:08:08,640 >>GOOD POINT. 3100 02:08:08,640 --> 02:08:10,560 WHOLE PERSON AND WHOLE HEALTH 3101 02:08:10,560 --> 02:08:12,680 WORKING IN THEME OF CONFERENCE. 3102 02:08:12,680 --> 02:08:14,160 THANKS SO MUCH AND DR. TUTLE 3103 02:08:14,160 --> 02:08:15,680 WILL BRING QUESTIONS FROM THE 3104 02:08:15,680 --> 02:08:17,040 GENERAL AUDIENCE. 3105 02:08:17,040 --> 02:08:18,680 >>YEAH. WE APPRECIATE EVERYONE 3106 02:08:18,680 --> 02:08:20,320 GOING A LITTLE LONG. WE WANTED 3107 02:08:20,320 --> 02:08:22,880 TO MAKE SURE WE HAD A ROBUST 3108 02:08:22,880 --> 02:08:23,960 DISCUSSION AND A FEW QUESTIONS 3109 02:08:23,960 --> 02:08:25,800 FROM THE AUDIENCE WE WOULD LIKE 3110 02:08:25,800 --> 02:08:27,640 TO ASK THE PANEL BEFORE WE BREAK 3111 02:08:27,640 --> 02:08:29,360 FOR LUNCH. FIRST IS WHAT IS 3112 02:08:29,360 --> 02:08:31,400 LIKELY EFFECT OF NEW HIGHLY 3113 02:08:31,400 --> 02:08:33,920 EFFECTIVE WEIGHT LOSS DRUGS ON 3114 02:08:33,920 --> 02:08:35,160 OSTEOARTHRITIS AND HOW WILL IT 3115 02:08:35,160 --> 02:08:37,960 EFFECT TRIALS LOOKING AT OTHER 3116 02:08:37,960 --> 02:08:40,160 TYPES OF NON-PHARMACOLOGICAL 3117 02:08:40,160 --> 02:08:42,680 INTERVENTIONS AND QUESTION IS 3118 02:08:42,680 --> 02:08:44,240 REFERRING TO OSDEM PICK OR 3119 02:08:44,240 --> 02:08:45,280 [INDISCERNIBLE] AND MARKET 3120 02:08:45,280 --> 02:08:47,000 DECREASE IN BODY WEIGHT THAT WE 3121 02:08:47,000 --> 02:08:48,080 ARE SHOWING SO FAR? 3122 02:08:48,080 --> 02:08:50,120 THIS TIES INTO MY EARLIER 3123 02:08:50,120 --> 02:08:52,240 QUESTION TO A CERTAIN EXTENT IS 3124 02:08:52,240 --> 02:08:54,960 IT OVERALL BIOMECHANICAL WEIGHT 3125 02:08:54,960 --> 02:08:56,240 REDUCTION OR WOULD DRUGS ALSO 3126 02:08:56,240 --> 02:08:59,600 MAYBE BE CHANGING, YOU KNOW, 3127 02:08:59,600 --> 02:09:03,240 LOCAL FACTORS IN ADIPOSE TISSUE 3128 02:09:03,240 --> 02:09:05,160 PROXIMAL TO THE JOINT AND 3129 02:09:05,160 --> 02:09:09,360 CURIOUS BEFORE ROHN OR MESSIER 3130 02:09:09,360 --> 02:09:10,960 OR OTHER PANELISTS THAT WOULD 3131 02:09:10,960 --> 02:09:16,840 LIKE TO CHIME IN ABOUT THIS? 3132 02:09:16,840 --> 02:09:20,200 >>GO AHEAD, DAN. 3133 02:09:20,200 --> 02:09:23,200 >>I DON'T SEE DAN COMING OFF 3134 02:09:23,200 --> 02:09:26,400 CAMERA. DR. MESSIER, WOULD YOU 3135 02:09:26,400 --> 02:09:28,880 LIKE TO TAKE THIS? 3136 02:09:28,880 --> 02:09:31,280 >>THE TREATMENT AND WEIGHT LOSS 3137 02:09:31,280 --> 02:09:33,400 IS REMARKABLE AND WE HAVE BEEN 3138 02:09:33,400 --> 02:09:34,920 THINKING TO DO A COMPARATIVE 3139 02:09:34,920 --> 02:09:40,440 EFFECT IN THIS TRIAL LOOKING AT 3140 02:09:40,440 --> 02:09:43,960 DIET AND EXERCISE VERSUS WEIGHT 3141 02:09:43,960 --> 02:09:45,880 LOSS DRUG AND IN PEOPLE WITH 3142 02:09:45,880 --> 02:09:48,080 KNEE OSTEOARTHRITIS SEEING IF 3143 02:09:48,080 --> 02:09:49,960 YOU GET THE SAME EFFECT AND 3144 02:09:49,960 --> 02:09:51,600 WHERE ONE LASTS LONGER THAN THE 3145 02:09:51,600 --> 02:09:53,040 OTHER. YOU KNOW? 3146 02:09:53,040 --> 02:09:54,920 WITH -- WITH PAIN AND FUNCTION. 3147 02:09:54,920 --> 02:10:03,120 BUT I WILL HAVE TO SAY THAT 3148 02:10:03,120 --> 02:10:05,360 STUDIES SO FAR HAVE BEEN DONE 3149 02:10:05,360 --> 02:10:07,320 CAREFULLY PUBLISHING GREAT 3150 02:10:07,320 --> 02:10:09,320 JOURNALS IN MEDICINE AND IN JAMB 3151 02:10:09,320 --> 02:10:12,160 AND EVERY ONE OF THEM AND 3152 02:10:12,160 --> 02:10:13,120 RESULTS ARE IMPRESSIVE. 3153 02:10:13,120 --> 02:10:15,240 THEY ARE -- IT LOOKS TO US LIKE 3154 02:10:15,240 --> 02:10:16,960 THEY ARE GETTING -- THEY ARE 3155 02:10:16,960 --> 02:10:18,680 HITTING BOTH PATHWAYS AND 3156 02:10:18,680 --> 02:10:20,960 HITTING BIOMECHANICAL PATHWAY 3157 02:10:20,960 --> 02:10:23,120 AND HITTING INFLAMMATORY PATHWAY 3158 02:10:23,120 --> 02:10:25,400 AT THE SAME TIME AND LOOKS LIKE 3159 02:10:25,400 --> 02:10:27,200 IMPACT IS IN THE SAME PATHWAYS 3160 02:10:27,200 --> 02:10:29,680 THAT DIET AND EXERCISE WOULD DO 3161 02:10:29,680 --> 02:10:32,360 AND QUESTION IS WHETHER -- 3162 02:10:32,360 --> 02:10:34,160 WHETHER -- WHETHER YOU GET THE 3163 02:10:34,160 --> 02:10:35,200 SAME EFFECT. 3164 02:10:35,200 --> 02:10:37,280 OTHER THING IS COST 3165 02:10:37,280 --> 02:10:38,160 EFFECTIVENESS OF IT. 3166 02:10:38,160 --> 02:10:41,520 OUR LARGE TRIALS WE DO COST 3167 02:10:41,520 --> 02:10:43,480 EFFECTIVENESS ANALYSIS AND 3168 02:10:43,480 --> 02:10:45,920 SOMETHING I HAVEN'T BROUGHT UP 3169 02:10:45,920 --> 02:10:48,960 DIET AND EXERCISE LONG TERM IS 3170 02:10:48,960 --> 02:10:50,080 HIGHLY COST EFFECTIVE AND 3171 02:10:50,080 --> 02:10:51,960 WHETHER THE DRUG WOULD COME UP 3172 02:10:51,960 --> 02:10:53,360 WITH SAME COST EFFECTIVENESS I 3173 02:10:53,360 --> 02:10:56,320 DON'T KNOW. IT IS ABOUT $1,000 3174 02:10:56,320 --> 02:10:57,360 A MONTH RIGHT NOW. 3175 02:10:57,360 --> 02:10:59,280 >>WOULD YOU DO THE TRIAL IN 3176 02:10:59,280 --> 02:11:00,800 THOSE WITH METABOLIC DISORDERS 3177 02:11:00,800 --> 02:11:03,240 OR DIABETES OR JUST USE IT IN 3178 02:11:03,240 --> 02:11:05,120 PATIENTS THAT WERE INDEPENDENT 3179 02:11:05,120 --> 02:11:07,240 OF THAT AND JUST USING IT FOR 3180 02:11:07,240 --> 02:11:08,200 THE WEIGHT LOSS. 3181 02:11:08,200 --> 02:11:10,480 >>YEAH. WE DO OSTEOARTHRITIS. 3182 02:11:10,480 --> 02:11:10,880 >>OKAY. 3183 02:11:10,880 --> 02:11:13,640 >>WE WOULD DO IT. IN FACT, 3184 02:11:13,640 --> 02:11:14,440 THERE IS A -- 3185 02:11:14,440 --> 02:11:17,320 >>I HAVE OSTEOARTHRITIS BUT IT 3186 02:11:17,320 --> 02:11:19,880 COULD BE A PATIENT WITH DIABETES 3187 02:11:19,880 --> 02:11:20,840 OR WITHOUT. 3188 02:11:20,840 --> 02:11:23,680 >>OH, YEAH IN FACT WEIGHT LOSS 3189 02:11:23,680 --> 02:11:25,120 DRUGS STARTED WITH PEOPLE WITH 3190 02:11:25,120 --> 02:11:25,360 DIABETES. 3191 02:11:25,360 --> 02:11:27,200 >>I'M ASKING THE QUESTION. YOU 3192 02:11:27,200 --> 02:11:29,360 HAVE CONFOUNDING VARIABLE OF 3193 02:11:29,360 --> 02:11:31,480 PAIN DISORDERS IN INDIVIDUALS 3194 02:11:31,480 --> 02:11:32,840 WITH DIABETES POTENTIALLY 3195 02:11:32,840 --> 02:11:34,840 WHEREAS IF YOU DO IT IN 3196 02:11:34,840 --> 02:11:35,640 INDIVIDUALS WITHOUT DIABETES. 3197 02:11:35,640 --> 02:11:36,200 >>YEAH. 3198 02:11:36,200 --> 02:11:37,840 >>IT IS A CLINICAL TRIAL. 3199 02:11:37,840 --> 02:11:40,160 >>YEAH, IT IS. IT IS TOUGH TO 3200 02:11:40,160 --> 02:11:41,840 DO WHEN YOU HAVE -- WHEN YOU ARE 3201 02:11:41,840 --> 02:11:45,040 GETTING PEOPLE WHO WITH BMIS 3202 02:11:45,040 --> 02:11:46,000 OVER 40. 3203 02:11:46,000 --> 02:11:48,240 A LOT OF THEM HAVE TYPE 2 3204 02:11:48,240 --> 02:11:50,280 DIABETES GOING WITH IT AND 3205 02:11:50,280 --> 02:11:52,120 WEIGHT LOSS GETS RID OF DIABETES 3206 02:11:52,120 --> 02:11:54,400 MOST OF THE TIME. IT IS 3207 02:11:54,400 --> 02:11:55,920 REMARKABLE IT DOES THAT. 3208 02:11:55,920 --> 02:12:00,120 >>THANK YOU DR. MESSIER. 3209 02:12:00,120 --> 02:12:03,800 DR. SLOOUKA QUESTION FOR YOU. 3210 02:12:03,800 --> 02:12:06,400 CAUSE INSTABILITY IN PATIENTS 3211 02:12:06,400 --> 02:12:07,640 WITH UNSTABLE JOINTS AND 3212 02:12:07,640 --> 02:12:10,120 DEPENDING ON INPUT FOR 3213 02:12:10,120 --> 02:12:11,400 MAINTAINING UNSTABLE JOINT? 3214 02:12:11,400 --> 02:12:17,640 >>I'M NOT SURE I HAVE EVER SEEN 3215 02:12:17,640 --> 02:12:21,000 DATA OF INTERRUPTION OF 3216 02:12:21,000 --> 02:12:21,880 PROPRIOCEPTION WITH TENS AND 3217 02:12:21,880 --> 02:12:24,040 THAT IS IF I THINK ABOUT IT AND 3218 02:12:24,040 --> 02:12:25,760 PEOPLE DON'T SEEM TO UNSTABLE 3219 02:12:25,760 --> 02:12:27,480 AND DON'T HAVE INCREASED FALLS 3220 02:12:27,480 --> 02:12:30,960 OR PEOPLE USING TENS IN ACTIVE. 3221 02:12:30,960 --> 02:12:33,360 WE DON'T SEE IT AS AN OUTCOME. 3222 02:12:33,360 --> 02:12:35,920 WE HAVE LOOKED AT THE SPECIFIC 3223 02:12:35,920 --> 02:12:38,720 QUESTION ON ADVERSE EVENT FORMS 3224 02:12:38,720 --> 02:12:40,880 AND DON'T SEE THAT. 3225 02:12:40,880 --> 02:12:43,840 I'M NO THE SURE THAT THAT IS 3226 02:12:43,840 --> 02:12:46,480 ACTUALLY HAPPENING AND I -- 3227 02:12:46,480 --> 02:12:47,080 UNLESS OTHER EVIDENCE THAT 3228 02:12:47,080 --> 02:12:49,920 PEOPLE HAVE, WE DOECHT SEE IT AS 3229 02:12:49,920 --> 02:12:51,520 AN ISSUE. 3230 02:12:51,520 --> 02:12:53,680 REDUCTION IN PAIN HELPS THEM 3231 02:12:53,680 --> 02:12:55,960 MOVE BETTER SO MAYBE THEY ARE 3232 02:12:55,960 --> 02:12:58,000 MOVING BETTER IN A MORE 3233 02:12:58,000 --> 02:12:59,160 COORDINATED MANNER ANYWAYS AND 3234 02:12:59,160 --> 02:13:01,080 MAYBE IT MAKES UP FOR IT. 3235 02:13:01,080 --> 02:13:03,640 >>THANK YOU DR. SLUKA. 3236 02:13:03,640 --> 02:13:06,400 I WOULD LIKE TO CIRCLE BACK TO 3237 02:13:06,400 --> 02:13:09,480 DR. GOERTZ WHO HAD TAKE-HOME 3238 02:13:09,480 --> 02:13:10,880 MESSAGES I WOULD LIKE TO HEAR 3239 02:13:10,880 --> 02:13:12,200 BUT DIDN'T HAVE TIME IN 3240 02:13:12,200 --> 02:13:14,200 INTRODUCTION AND WOULD YOU LIKE 3241 02:13:14,200 --> 02:13:15,880 TO SHARE YOUR LAST PORTION OF 3242 02:13:15,880 --> 02:13:17,000 YOUR THOUGHTS FROM THE WORKSHOP? 3243 02:13:17,000 --> 02:13:23,360 >>I WOULD BE HAPPY TO. THANKS 3244 02:13:23,360 --> 02:13:26,280 SO MUCH, ALEX. THIS HAS BEEN A 3245 02:13:26,280 --> 02:13:29,360 TERRIFIC SESSION. I REAL 3246 02:13:29,360 --> 02:13:31,320 ENJOYED THE RICH DISCUSSION. 3247 02:13:31,320 --> 02:13:34,280 I THINK IT ILLUSTRATES THE 3248 02:13:34,280 --> 02:13:35,560 COMPLEXITY WE FACE CONSIDERING 3249 02:13:35,560 --> 02:13:38,800 WIDE RANGE OF TREATMENTS 3250 02:13:38,800 --> 02:13:42,160 AVAILABLE TO PATIENTS THAT WE 3251 02:13:42,160 --> 02:13:43,320 ARE ALL STUDYING AND YOU 3252 02:13:43,320 --> 02:13:45,240 COULDN'T HAVE PICKED A BETTER 3253 02:13:45,240 --> 02:13:48,200 REPRESENTATION OF THE BROADNESS 3254 02:13:48,200 --> 02:13:51,240 OF THOSE THAN EVERYTHING FROM 3255 02:13:51,240 --> 02:13:54,960 DIET TO EXERCISE TO -- TO 3256 02:13:54,960 --> 02:13:56,360 INJECTIONS AND ONE PROBLEM WE 3257 02:13:56,360 --> 02:13:59,520 FACE IS THAT RESEARCH HAS BEEN 3258 02:13:59,520 --> 02:14:00,880 MENTIONED SEVERAL TIMES ALREADY 3259 02:14:00,880 --> 02:14:03,720 THAT TENDS TO FOCUS ON ISOLATED 3260 02:14:03,720 --> 02:14:05,360 TREATMENTS RATHER THAN 3261 02:14:05,360 --> 02:14:08,480 MULTIMODAL APPROACHES THAT 3262 02:14:08,480 --> 02:14:11,960 PATIENTS ARE MORE LIKELY TO FACE 3263 02:14:11,960 --> 02:14:12,600 CLINICALLY. 3264 02:14:12,600 --> 02:14:14,360 AND THE OTHER THING THAT -- THAT 3265 02:14:14,360 --> 02:14:18,160 I FEEL THAT WE TEND TO SHALL 3266 02:14:18,160 --> 02:14:20,400 THAT, YOU KNOW, THOSE OF US WHO 3267 02:14:20,400 --> 02:14:23,120 ARE NIH SUPPORTED SCIENTISTS 3268 02:14:23,120 --> 02:14:25,640 ABOUT YOU CLINICALLY AS WELL WE 3269 02:14:25,640 --> 02:14:29,400 ARE STILL TENDING TO FOCUS MUCH 3270 02:14:29,400 --> 02:14:33,400 MORE ON BIOPART OF THE 3271 02:14:33,400 --> 02:14:35,320 BIOPSYCHOSOCIAL MODEL AND NOT ON 3272 02:14:35,320 --> 02:14:38,640 THE SOCIAL PART OF THE MODEL AT 3273 02:14:38,640 --> 02:14:39,360 ALL. 3274 02:14:39,360 --> 02:14:43,040 I THINK THAT, THAT LACK OF FOCUS 3275 02:14:43,040 --> 02:14:45,280 MAY BE RESPONSIBLE FOR SOME OF 3276 02:14:45,280 --> 02:14:48,160 THE GAPS THAT WE HAVE BEEN 3277 02:14:48,160 --> 02:14:52,000 DISCUSSING SO FAR AT THIS 3278 02:14:52,000 --> 02:14:52,240 MEETING. 3279 02:14:52,240 --> 02:14:56,000 I'M INSPIRED AND CHALLENGED BY 3280 02:14:56,000 --> 02:15:00,640 THAT AND IDEAS AND WORK OF THE 3281 02:15:00,640 --> 02:15:02,200 WORKSHOP PARTICIPANTS AND ALSO 3282 02:15:02,200 --> 02:15:03,720 FROM A SCIENTIFIC PERSPECTIVE 3283 02:15:03,720 --> 02:15:07,600 AND ALSO BECAUSE OF THE 3284 02:15:07,600 --> 02:15:09,360 CONVERSATIONS THAT HAVE OCCURRED 3285 02:15:09,360 --> 02:15:10,640 THROUGHOUT THIS ENTIRE WORKSHOP 3286 02:15:10,640 --> 02:15:13,000 ABOUT THE NEED TO FOCUS MORE AND 3287 02:15:13,000 --> 02:15:16,360 IMPLEMENTATION AND, YOU KNOW, 3288 02:15:16,360 --> 02:15:17,600 IMPLEMENTATION SCIENCE. 3289 02:15:17,600 --> 02:15:20,360 I THINK THERE ARE REAL 3290 02:15:20,360 --> 02:15:21,920 OPPORTUNITIES FOR CROSS-CUTTING 3291 02:15:21,920 --> 02:15:25,360 COLLABORATIONS THAT NIH ACTUALLY 3292 02:15:25,360 --> 02:15:29,360 PROVIDES A UNIQUE OPPORTUNITY TO 3293 02:15:29,360 --> 02:15:30,640 FACILITATE COLLABORATIONS AND 3294 02:15:30,640 --> 02:15:32,240 THIS WORKSHOP IS A GREAT STEP IN 3295 02:15:32,240 --> 02:15:33,400 THE RIGHT DIRECTION AND I'M 3296 02:15:33,400 --> 02:15:35,120 HOPING THERE ARE WAYS TO -- THAT 3297 02:15:35,120 --> 02:15:40,880 WE ARE ABLE TO CONTINUE THESE 3298 02:15:40,880 --> 02:15:43,520 CONVERSATIONS. 3299 02:15:43,520 --> 02:15:44,880 >>VERY GOOD. THANK YOU FOR THE 3300 02:15:44,880 --> 02:15:46,560 REST OF THE THOUGHTS AND I WOULD 3301 02:15:46,560 --> 02:15:48,280 LIKE TO CONCLUDE THIS SESSION 3302 02:15:48,280 --> 02:15:49,920 AND THANKS ALL FOR STAYING ON 3303 02:15:49,920 --> 02:15:51,960 AND THIS IS A ROBUST DISCUSSION 3304 02:15:51,960 --> 02:15:54,640 AND WANT TO THANK ALL SPEAKERS 3305 02:15:54,640 --> 02:15:55,600 AND PANELISTS FOR THE 3306 02:15:55,600 --> 02:15:56,600 PARTICIPATION TODAY AND WOULD 3307 02:15:56,600 --> 02:16:03,800 LIKE TO THANK DR. SLUKA AND 3308 02:16:03,800 --> 02:16:06,160 OSHINSKY WHO SERVED AS CO-CHAIRS 3309 02:16:06,160 --> 02:16:07,600 PUTTING THIS TOGETHER AND WE 3310 02:16:07,600 --> 02:16:09,320 WILL BREAK FOR LUNCH AND RETURN 3311 02:16:09,320 --> 02:16:11,680 AT 1 P.M. STOP YOUR VIDEO AND 3312 02:16:11,680 --> 02:16:12,400 MUTE YOURSELF THAT WOULD BE 3313 02:16:12,400 --> 02:16:14,600 GRAEK AND WE WILL COME BACK AND 3314 02:16:14,600 --> 02:16:16,440 HAVE NEXT SCIENTIFIC SESSION 3315 02:16:16,440 --> 02:16:18,920 EMERGING TECHNOLOGIES AND 3316 02:16:18,920 --> 02:16:20,560 EMERGING MODELS AND THANK YOU, 3317 02:16:20,560 --> 02:16:21,800 EVERYONE. 3318 02:16:21,800 --> 02:16:24,640 >>WELCOME BACK. 3319 02:16:24,640 --> 02:16:28,760 WE ARE NOW KICKING OFF SESSION 5 3320 02:16:28,760 --> 02:16:30,480 OF OUR WORKSHOP TODAY. 3321 02:16:30,480 --> 02:16:33,840 THIS SESSION IS CHAIRED BY DR. 3322 02:16:33,840 --> 02:16:34,240 DUAN. 3323 02:16:34,240 --> 02:16:37,120 NATIONAL INSTITUTE OF BIOMEDICAL 3324 02:16:37,120 --> 02:16:39,160 IMAGING AND BIOENGINEERING. 3325 02:16:39,160 --> 02:16:43,600 OUR CO-CHAIRS ARE DR. BACHMAN OF 3326 02:16:43,600 --> 02:16:47,560 NINDS AND DR. LATTANZI OF NEW 3327 02:16:47,560 --> 02:16:48,320 YORK UNIVERSITY. 3328 02:16:48,320 --> 02:16:50,840 I'M GOING TO MOVE TO SPEAKER 3329 02:16:50,840 --> 02:16:52,480 SLIDE TO INTRODUCE SPEAKERS 3330 02:16:52,480 --> 02:16:55,680 BRIEFLY FOR OUR SESSION. 3331 02:16:55,680 --> 02:16:56,760 >>THANK YOU. 3332 02:16:56,760 --> 02:16:59,680 WE HAVE FOUR SPEAKERS FOR THIS 3333 02:16:59,680 --> 02:17:03,560 SESSION, FIRST SPEAKER IS MY 3334 02:17:03,560 --> 02:17:05,280 CO-CHAIR, DR. LATTANZI FROM NEW 3335 02:17:05,280 --> 02:17:08,160 YORK UNIVERSITY. 3336 02:17:08,160 --> 02:17:10,320 NEXT IS DR. PEDOIA FROM 3337 02:17:10,320 --> 02:17:13,400 UNIVERSITY OF CALIFORNIA, SAN 3338 02:17:13,400 --> 02:17:13,840 FRANCISCO. 3339 02:17:13,840 --> 02:17:16,360 DR. KEVIN KOCH FROM MEDICAL 3340 02:17:16,360 --> 02:17:19,520 COLLEGE OF WISCONSIN FOLLOWED BY 3341 02:17:19,520 --> 02:17:21,400 DR. YIN FROM MAYO CLINIC. 3342 02:17:21,400 --> 02:17:24,800 NEXT SLIDE. 3343 02:17:24,800 --> 02:17:28,520 WE HAVE FOUR PANELISTS FOR 3344 02:17:28,520 --> 02:17:29,400 ADDITIONAL PERSPECTIVES, DR. 3345 02:17:29,400 --> 02:17:33,440 SCOTT BANKS FROM UNIVERSITY OF 3346 02:17:33,440 --> 02:17:36,920 FLORIDA, DR. KOGAN FROM STANFORD 3347 02:17:36,920 --> 02:17:38,160 UNIVERSITY, DR. CEVIDANES 3348 02:17:38,160 --> 02:17:42,280 UNIVERSITY OF MICHIGAN, AND DR. 3349 02:17:42,280 --> 02:17:43,280 SIKDAR FROM GEORGE MASON 3350 02:17:43,280 --> 02:17:44,840 UNIVERSITY. 3351 02:17:44,840 --> 02:17:46,960 WITH THAT I PASS TO THE CO-CHAIR 3352 02:17:46,960 --> 02:17:48,200 FOR THE FIRST TALK. 3353 02:17:48,200 --> 02:17:52,160 THANK YOU. 3354 02:17:52,160 --> 02:17:53,280 >>OKAY. 3355 02:17:53,280 --> 02:18:03,680 LET ME SHARE MY SCREEN. 3356 02:18:04,800 --> 02:18:08,400 YOU SHOULD BE ABLE TO SEE IT 3357 02:18:08,400 --> 02:18:14,080 NOW. 3358 02:18:14,080 --> 02:18:16,000 SO GOOD AFTERNOON. 3359 02:18:16,000 --> 02:18:17,680 I NEED DISCLOSE I HAVE A PATENT 3360 02:18:17,680 --> 02:18:22,040 RELATED TO THE TOPIC OF THE 3361 02:18:22,040 --> 02:18:24,720 PRESENTATION, SO WHAT DO WE 3362 02:18:24,720 --> 02:18:24,920 MEAN? 3363 02:18:24,920 --> 02:18:26,760 QUANTITATIVE MRI IS WHEN THE 3364 02:18:26,760 --> 02:18:28,560 SCANNER IS NOT USED AS A CAMERA 3365 02:18:28,560 --> 02:18:31,160 TO TAKE PHYSICAL PICTURES BUT AS 3366 02:18:31,160 --> 02:18:32,680 A SCIENTIFIC MEASURING 3367 02:18:32,680 --> 02:18:33,560 INSTRUMENT TO GENERATE 3368 02:18:33,560 --> 02:18:38,480 QUANTITATIVE MAPS THAT CAN SHOW 3369 02:18:38,480 --> 02:18:39,840 SPECIFIC BIOLOGICAL CHANGES. 3370 02:18:39,840 --> 02:18:45,400 THIS IS A HIP JOINT SHOWN FROM 3371 02:18:45,400 --> 02:18:48,560 AN IMAGE ACQUIRED ALONG A 3372 02:18:48,560 --> 02:18:54,600 RADIOSECTION OF THE HIP, YOU SEE 3373 02:18:54,600 --> 02:18:57,320 ACETABULUM, THE LABRUM. 3374 02:18:57,320 --> 02:19:03,560 IT CALCULATES A THIN STRUCTURE, 3375 02:19:03,560 --> 02:19:05,760 TO DETECT LESIONS, REPORTING THE 3376 02:19:05,760 --> 02:19:08,520 CARTILAGE AS NORMAL BECAUSE IT 3377 02:19:08,520 --> 02:19:13,320 LOOKS NORMAL. 3378 02:19:13,320 --> 02:19:17,840 HOWEVER, THE PATIENT -- THE 3379 02:19:17,840 --> 02:19:20,240 SURGEON FOUND HUGE PORTION WAS 3380 02:19:20,240 --> 02:19:21,800 COMPLETELY DELAMINATED. 3381 02:19:21,800 --> 02:19:27,440 IF WE LOOK AT THE STANDARDIZED 3382 02:19:27,440 --> 02:19:31,080 MAP, SUPERIMPOSED, WE SEE THE 3383 02:19:31,080 --> 02:19:34,760 CARTILAGE LESION STANDS OUT. 3384 02:19:34,760 --> 02:19:37,600 THIS IS AN EXAMPLE TO QUANTIFY 3385 02:19:37,600 --> 02:19:47,160 LOSS OF LIGANDS, AN EARLY CHANGE 3386 02:19:47,160 --> 02:19:49,840 IN CALCULATION. 3387 02:19:49,840 --> 02:19:51,160 IT CAN DETECT EARLY CHANGES WITH 3388 02:19:51,160 --> 02:19:54,800 A SCORE OF 1 IN WHICH THE 3389 02:19:54,800 --> 02:19:57,760 CALCULATION LOOKS INTACT BUT 3390 02:19:57,760 --> 02:20:00,480 DAMAGE AT THE MECHANICAL LEVEL. 3391 02:20:00,480 --> 02:20:02,120 EARLY CHANGES ARE REVERSIBLE SO 3392 02:20:02,120 --> 02:20:05,000 EARLY DETECTION COULD ENABLE THE 3393 02:20:05,000 --> 02:20:06,560 SURGEON TO INTERVENE WHEN IT'S 3394 02:20:06,560 --> 02:20:10,280 POSSIBLE TO PREVENT DAMAGE THAT 3395 02:20:10,280 --> 02:20:12,400 WOULD LEAD TO OSTEOARTHRITIS. 3396 02:20:12,400 --> 02:20:15,960 THERE ARE MANY QUANTITATIVE 3397 02:20:15,960 --> 02:20:22,880 PARAMETERS USED TO CHARACTERIZE 3398 02:20:22,880 --> 02:20:25,480 (INDISCERNIBLE) AND MANY 3399 02:20:25,480 --> 02:20:26,840 TECHNIQUES TO MEASURE THEM 3400 02:20:26,840 --> 02:20:28,360 DEVELOPED OVER THE YEARS. 3401 02:20:28,360 --> 02:20:29,880 IT'S ALSO BEEN SHOWN 3402 02:20:29,880 --> 02:20:32,320 QUANTITATIVE MRI CAN BE 3403 02:20:32,320 --> 02:20:32,880 EFFECTIVE IN CHARACTERIZING 3404 02:20:32,880 --> 02:20:33,600 JOINT DISEASES. 3405 02:20:33,600 --> 02:20:35,560 WHY IT'S NOT USED CLINICALLY? 3406 02:20:35,560 --> 02:20:38,840 THERE ARE SEVERAL REASONS FOR 3407 02:20:38,840 --> 02:20:39,320 THAT. 3408 02:20:39,320 --> 02:20:41,160 ONE IS CERTAINLY SCAN TIME, A 3409 02:20:41,160 --> 02:20:42,880 SINGLE PARAMETER IS NOT 3410 02:20:42,880 --> 02:20:43,920 SUFFICIENT TO COMPLETELY 3411 02:20:43,920 --> 02:20:45,440 CHARACTERIZE STATUS OF CARTILAGE 3412 02:20:45,440 --> 02:20:46,840 AND SURROUNDING STRUCTURE SO WE 3413 02:20:46,840 --> 02:20:49,280 NEED TO MAP MULTIPLE PARAMETERS, 3414 02:20:49,280 --> 02:20:54,200 THAT CAN TAKE TIME. 3415 02:20:54,200 --> 02:20:57,800 AND TECHNIQUES PROPOSED OFTEN AT 3416 02:20:57,800 --> 02:21:05,960 THE DISPENSE OF ACCURACY. 3417 02:21:05,960 --> 02:21:09,400 MANY BOTTLE NECK IS REGISTRATION 3418 02:21:09,400 --> 02:21:11,680 AND SEGMENTATION. 3419 02:21:11,680 --> 02:21:14,640 FINALLY QUANTITATIVE MR 3420 02:21:14,640 --> 02:21:15,600 PARAMETERS CORRELATED WITH 3421 02:21:15,600 --> 02:21:16,960 CLINICAL FINDINGS AND OUTCOME 3422 02:21:16,960 --> 02:21:21,120 BUT INTERPRETATION IS LACKING, 3423 02:21:21,120 --> 02:21:25,400 SO TODAY I WOULD LIKE TO FOCUS 3424 02:21:25,400 --> 02:21:28,840 ON A MODEL BASED QUANTITATIVE 3425 02:21:28,840 --> 02:21:30,840 MRI TECHNIQUE ADDRESSING THE 3426 02:21:30,840 --> 02:21:32,200 FIRST TWO BULLET POINTS TO HELP 3427 02:21:32,200 --> 02:21:34,520 BOTH OF THE OTHER TWO 3428 02:21:34,520 --> 02:21:35,080 CONSIDERABLY. 3429 02:21:35,080 --> 02:21:39,920 IT WAS INTRODUCED TEN YEARS AGO, 3430 02:21:39,920 --> 02:21:42,360 MOST REMAIN LIMITED. 3431 02:21:42,360 --> 02:21:43,320 WHAT IS MR FINGERPRINTING? 3432 02:21:43,320 --> 02:21:48,360 IF YOU THINK OF TRADITIONAL MR 3433 02:21:48,360 --> 02:21:53,840 PARAMETER MAPPING WHAT WE DO IS 3434 02:21:53,840 --> 02:21:58,000 TRY TO MAKE BEHAVIOR BE 3435 02:21:58,000 --> 02:21:59,880 EXPLAINED USING SIMPLIFIED 3436 02:21:59,880 --> 02:22:01,440 MODEL. 3437 02:22:01,440 --> 02:22:03,040 MR FINGERPRINTING IS A 3438 02:22:03,040 --> 02:22:06,880 COMPLETELY DIFFERENT APPROACH. 3439 02:22:06,880 --> 02:22:09,320 WE LET IT THE SPINS DANCE FREELY 3440 02:22:09,320 --> 02:22:11,640 TO UNDERSTAND WHAT THEY ARE 3441 02:22:11,640 --> 02:22:12,440 TELLING US. 3442 02:22:12,440 --> 02:22:15,360 AND WE WILL SEE MORE OF THIS BUT 3443 02:22:15,360 --> 02:22:17,120 HAVE A TIME-SERIES OF HIGHLY 3444 02:22:17,120 --> 02:22:20,760 UNDERSTAMPED IMAGES THAT CAPTURE 3445 02:22:20,760 --> 02:22:23,040 TIME-DEPENDENT SPIN EVOLUTION, 3446 02:22:23,040 --> 02:22:26,040 THE FINGERPRINT, AND IDENTIFIED 3447 02:22:26,040 --> 02:22:27,240 THE UNDERLYING TISSUE 3448 02:22:27,240 --> 02:22:27,720 PROPERTIES. 3449 02:22:27,720 --> 02:22:34,040 M PROSECUTORS PARAMETER MAPS -- 3450 02:22:34,040 --> 02:22:38,400 MR PARAMETER MAPS ARE 3451 02:22:38,400 --> 02:22:41,280 RECONSTRUCTED. 3452 02:22:41,280 --> 02:22:44,680 AND THIS IS THE MRF SHALL, I 3453 02:22:44,680 --> 02:22:47,440 WANT TO POINT OUT THERE ARE TWO 3454 02:22:47,440 --> 02:22:49,280 KEY CONCEPTS IN MR 3455 02:22:49,280 --> 02:22:50,920 FINGERPRINTING, FIRST IS 3456 02:22:50,920 --> 02:22:52,120 TEMPORAL INCOHERENCE, WE WANT 3457 02:22:52,120 --> 02:22:53,360 THE SIGNAL FROM DIFFERENT 3458 02:22:53,360 --> 02:22:54,840 TISSUES TO LOOK DIFFERENT IN 3459 02:22:54,840 --> 02:22:58,560 TIME. 3460 02:22:58,560 --> 02:23:00,800 WE DID THAT BY VARYING THE 3461 02:23:00,800 --> 02:23:03,720 POSITIONS, THESE PARAMETERS CAN 3462 02:23:03,720 --> 02:23:05,800 BE OPTIMIZED FOR SPECIFIC TISSUE 3463 02:23:05,800 --> 02:23:07,400 PROPERTIES. 3464 02:23:07,400 --> 02:23:08,760 WE WANT SPATIAL INCOHERENCE, 3465 02:23:08,760 --> 02:23:11,040 DIFFERENT SPATIAL LOCATION TO 3466 02:23:11,040 --> 02:23:16,320 LOOK DIFFERENT IN TIME. 3467 02:23:16,320 --> 02:23:21,400 IN THIS CASE THE TRAJECTORY WAS 3468 02:23:21,400 --> 02:23:28,720 SPIRAL, YOU CAN ENFORCE BY 3469 02:23:28,720 --> 02:23:31,200 ROTATING SPIRALS. 3470 02:23:31,200 --> 02:23:32,760 AND NEEDS TO BE FAST. 3471 02:23:32,760 --> 02:23:37,880 BECAUSE OF THE HIGH DEGREE OF 3472 02:23:37,880 --> 02:23:39,840 UNDERSAMPLING, FOR EXAMPLE THIS 3473 02:23:39,840 --> 02:23:40,960 IMAGE FROM THE PUBLICATION 3474 02:23:40,960 --> 02:23:43,080 SUPPOSED TO SHOW A BRAIN BUT YOU 3475 02:23:43,080 --> 02:23:46,880 NEED SOME IMAGINATION TO SEE A 3476 02:23:46,880 --> 02:23:50,880 BRAIN IN THESE IMAGES. 3477 02:23:50,880 --> 02:23:53,560 WHAT WE OBTAIN IS THESE IMAGES. 3478 02:23:53,560 --> 02:23:55,320 BECAUSE OF THE INCOHERENCE THAT 3479 02:23:55,320 --> 02:24:01,680 WAS ENFORCED DURING ACQUISITION 3480 02:24:01,680 --> 02:24:02,760 ARTIFACT WAS (INDISCERNIBLE) 3481 02:24:02,760 --> 02:24:04,960 FILTERED OUT BY THE FOLLOWING 3482 02:24:04,960 --> 02:24:05,160 STEPS. 3483 02:24:05,160 --> 02:24:10,000 ONCE WE HAVE THE STACK OF 3484 02:24:10,000 --> 02:24:13,720 IMAGES, THE VOXEL, CORRESPONDING 3485 02:24:13,720 --> 02:24:20,840 SIGNAL FINGERPRINT WHICH ENCODES 3486 02:24:20,840 --> 02:24:22,040 QUANTITATIVE INFORMATION. 3487 02:24:22,040 --> 02:24:29,600 WE USE BLOCK EQUATIONS WE'RE 3488 02:24:29,600 --> 02:24:30,800 INTERESTED IN QUANTIFYING, AND 3489 02:24:30,800 --> 02:24:36,520 ONCE WE HAVE THIS DICTIONARY WE 3490 02:24:36,520 --> 02:24:38,680 TAKE THE SIGNAL AND FIND THE 3491 02:24:38,680 --> 02:24:40,200 MOST SIMILAR ONE IN THE 3492 02:24:40,200 --> 02:24:42,120 DICTIONARY AND ONCE WE MEASURE 3493 02:24:42,120 --> 02:24:47,640 FINGERPRINT WE KNOW EXACTLY WHAT 3494 02:24:47,640 --> 02:24:51,880 ARE THE TISSUE AND REPEAT FOR 3495 02:24:51,880 --> 02:24:55,720 ALL VOXEL AND OBTAIN MR MAPS. 3496 02:24:55,720 --> 02:24:59,440 OUR GROUP WAS THE FIRST TO USE 3497 02:24:59,440 --> 02:25:01,520 FOR ASSESSMENT OF CALCULUS, 3498 02:25:01,520 --> 02:25:03,920 DEVELOPED A SEQUENCE FOR 3499 02:25:03,920 --> 02:25:06,000 MULTI-PARAMETER ASSESSMENT OF 3500 02:25:06,000 --> 02:25:07,760 CARTILAGE TARGETING RESOLUTION 3501 02:25:07,760 --> 02:25:09,760 IN PLANE AND USE RADIAL SECTIONS 3502 02:25:09,760 --> 02:25:15,320 OF THE HIP TO ELIMINATE PARTIAL 3503 02:25:15,320 --> 02:25:18,800 (INDISCERNIBLE) ALONG THE 3504 02:25:18,800 --> 02:25:20,760 THICKNESS, WITH 7-MINUTE SCAN 3505 02:25:20,760 --> 02:25:23,200 OBTAIN MAPS ALONG SIX RADIAL 3506 02:25:23,200 --> 02:25:26,560 SECTIONS COVERING THE ENTIRE 3507 02:25:26,560 --> 02:25:27,240 JOINT. 3508 02:25:27,240 --> 02:25:34,280 SIMILAR MR FINGERPRINTING 3509 02:25:34,280 --> 02:25:35,520 TECHNIQUE WAS DEVELOPED, ALSO 3510 02:25:35,520 --> 02:25:39,280 WITH TIME OF 7 MINUTES, CAN 3511 02:25:39,280 --> 02:25:41,920 PROVIDE INFORMATION ABOUT 3512 02:25:41,920 --> 02:25:43,200 LIGANDS, COLLAGEN, HYDRATION, 3513 02:25:43,200 --> 02:25:44,880 MORE COMPREHENSIVE ASSESSMENT OF 3514 02:25:44,880 --> 02:25:47,960 CARTILAGE IN A SINGLE SCAN, 3515 02:25:47,960 --> 02:25:53,080 RECONSTRUCTIVE FROM THE SAME 3516 02:25:53,080 --> 02:25:53,400 ACQUISITION. 3517 02:25:53,400 --> 02:25:56,120 AND EVALUATED AGAINST THE GOLD 3518 02:25:56,120 --> 02:26:01,520 STANDARD METHODS SHOWING 3519 02:26:01,520 --> 02:26:06,080 QUANTIFIED PARAMETERS ARE HIGHLY 3520 02:26:06,080 --> 02:26:12,440 ACCURATE, MATCHING ON THE AXIS. 3521 02:26:12,440 --> 02:26:14,440 IT IS MODEL BASED. 3522 02:26:14,440 --> 02:26:18,800 DICTIONARY GENERATED WITH BLOCK 3523 02:26:18,800 --> 02:26:21,200 EQUATIONS, MATCHED ON SIGNAL, IT 3524 02:26:21,200 --> 02:26:24,080 IS ALSO HIGHLY REPRODUCIBLE 3525 02:26:24,080 --> 02:26:26,160 ACROSS DIFFERENT MR SYSTEMS AND 3526 02:26:26,160 --> 02:26:27,920 REPEATED SCANS. 3527 02:26:27,920 --> 02:26:29,400 THE IN VIVO REPRODUCIBILITY 3528 02:26:29,400 --> 02:26:31,080 STUDIES SHOW THE PARAMETER 3529 02:26:31,080 --> 02:26:33,360 VALUES ARE NEARLY IDENTICAL 3530 02:26:33,360 --> 02:26:37,080 ACROSS MR SYSTEMS AND REGULAR 3531 02:26:37,080 --> 02:26:40,040 SCANS. 3532 02:26:40,040 --> 02:26:45,080 SO, THOSE ARE MR FINGERPRINTING 3533 02:26:45,080 --> 02:26:47,520 CAN ALSO HELP WITH OTHER 3534 02:26:47,520 --> 02:26:48,480 CHALLENGES CURRENTLY PREVENTING 3535 02:26:48,480 --> 02:26:50,440 THE CLINICAL CALCULATION OF 3536 02:26:50,440 --> 02:26:52,640 QUANTITATIVE MRI TECHNIQUES. 3537 02:26:52,640 --> 02:26:54,800 FOR EXAMPLE, MR FINGERPRINTING 3538 02:26:54,800 --> 02:26:57,600 ACQUISITION CONTAINS A LOT OF 3539 02:26:57,600 --> 02:27:00,000 DATA AND GENERATES MULTIPLE MAPS 3540 02:27:00,000 --> 02:27:01,280 SAME JOINT STRUCTURES HAVE 3541 02:27:01,280 --> 02:27:05,080 DIFFERENT DISTRIBUTION OF VALUE, 3542 02:27:05,080 --> 02:27:06,880 EXPLOITED FOR AUTOMATIC 3543 02:27:06,880 --> 02:27:08,200 CALCULATED SEGMENTATION USING 3544 02:27:08,200 --> 02:27:08,840 MACHINE LANGUAGE AN OPEN 3545 02:27:08,840 --> 02:27:13,680 CHALLENGE FOR THE HIP AT LEAST. 3546 02:27:13,680 --> 02:27:15,880 IN ORDER TO CHARACTERIZE WITH 3547 02:27:15,880 --> 02:27:17,400 QUANTITATIVE MRI WE ALSO NEED TO 3548 02:27:17,400 --> 02:27:18,840 UNDERSTAND WHAT MR PARAMETERS 3549 02:27:18,840 --> 02:27:19,960 TELL US ABOUT UNDERLYING 3550 02:27:19,960 --> 02:27:20,160 BIOLOGY. 3551 02:27:20,160 --> 02:27:30,680 THIS MEANS WE NEED TO PROCESS 3552 02:27:31,720 --> 02:27:34,040 ANNUAL ANALYZE CLINICAL 3553 02:27:34,040 --> 02:27:34,360 INFORMATION. 3554 02:27:34,360 --> 02:27:37,320 ON THE LEFT DOESN'T PROVIDE MUCH 3555 02:27:37,320 --> 02:27:39,200 INSIGHT INTO STANDARDIZED MAPS 3556 02:27:39,200 --> 02:27:41,600 THAT ENABLE DETECTION AND 3557 02:27:41,600 --> 02:27:45,760 QUANTIFICATION OF EARLY CALCULUS 3558 02:27:45,760 --> 02:27:46,200 DAMAGE. 3559 02:27:46,200 --> 02:27:51,200 RELIES ON TIME CONSUMING AND 3560 02:27:51,200 --> 02:27:51,640 COMPLEX PROCEDURE. 3561 02:27:51,640 --> 02:27:53,400 TRANSLATION CAN ONLY HAPPEN I 3562 02:27:53,400 --> 02:27:55,440 WOULD SAY WITH AUTOMATIC 3563 02:27:55,440 --> 02:27:56,480 PROCESSING PIPELINES. 3564 02:27:56,480 --> 02:28:02,040 AND WE HAVE NOT DONE MUCH IN THE 3565 02:28:02,040 --> 02:28:03,920 DIRECTION YET BUT 3566 02:28:03,920 --> 02:28:07,520 MUSCULOSKELETAL IMAGING TEAM AT 3567 02:28:07,520 --> 02:28:09,040 UCSF HAS BEEN AT THE FOREFRONT 3568 02:28:09,040 --> 02:28:10,920 AND THE NEXT SPEAKER IS A 3569 02:28:10,920 --> 02:28:15,880 PIONEER IN DEVELOPING MACHINE 3570 02:28:15,880 --> 02:28:17,400 LEARNING TECHNIQUES. 3571 02:28:17,400 --> 02:28:23,400 I WANT TO BRIEFLY HIGHLIGHT HER 3572 02:28:23,400 --> 02:28:31,880 GROUP'S WORK ON VOXEL BASED 3573 02:28:31,880 --> 02:28:33,000 RELAX OMETRY. 3574 02:28:33,000 --> 02:28:35,200 ANOTHER INTERESTING THING WE CAN 3575 02:28:35,200 --> 02:28:37,400 DO WITH MR FINGERPRINTING TO USE 3576 02:28:37,400 --> 02:28:43,840 SIMULTANEOUSLY ACQUIRED MR MAPS 3577 02:28:43,840 --> 02:28:44,920 TO GENERATE SYNTHETIC MORE 3578 02:28:44,920 --> 02:28:47,880 THANOLOGIC IMAGES. 3579 02:28:47,880 --> 02:28:50,080 THERE ARE SEVERAL ALGORITHMS FOR 3580 02:28:50,080 --> 02:28:52,480 THIS AND CLINICAL VALIDATION IS 3581 02:28:52,480 --> 02:28:53,240 ONGOING. 3582 02:28:53,240 --> 02:28:56,720 THE CLEAR ADVANTAGE WE COULD RUN 3583 02:28:56,720 --> 02:28:57,880 A 7-MINUTE FINGERPRINTING 3584 02:28:57,880 --> 02:28:58,880 ACQUISITION, IN ADDITION 3585 02:28:58,880 --> 02:29:01,400 QUANTITATIVE MAPS GENERATE ALSO 3586 02:29:01,400 --> 02:29:03,440 ALL THE STANDARD MR IMAGES 3587 02:29:03,440 --> 02:29:05,960 WITHOUT ADDITIONAL SCAN TIME. 3588 02:29:05,960 --> 02:29:11,400 THIS COULD FACILITATE CLINICAL 3589 02:29:11,400 --> 02:29:12,600 TRANSLATION OF QUANTITATIVE MRI. 3590 02:29:12,600 --> 02:29:13,440 >>TWO MINUTES. 3591 02:29:13,440 --> 02:29:14,280 >>YES. 3592 02:29:14,280 --> 02:29:17,880 I WANT TO CONCLUDE BY SHOWING IN 3593 02:29:17,880 --> 02:29:20,480 ADDITION TO USING QUANTITATIVE 3594 02:29:20,480 --> 02:29:24,160 MRI, IN CHARACTERIZE OF JOINT 3595 02:29:24,160 --> 02:29:27,800 USING MORPHOLOGIC MRI, IN THIS 3596 02:29:27,800 --> 02:29:29,640 PAPER THE ACETABULUM SEGMENTED 3597 02:29:29,640 --> 02:29:34,680 FROM 3D MRI DATA, MODEL TRAINED 3598 02:29:34,680 --> 02:29:37,760 TO DISCRIMINATE WITH AND WITHOUT 3599 02:29:37,760 --> 02:29:41,240 WITH 97% SENSITIVITY AND 3600 02:29:41,240 --> 02:29:45,000 SPECIFICITY, HIGHER THAN THE 3601 02:29:45,000 --> 02:29:47,600 PERFORMANCE OF RADIOLOGIC 3602 02:29:47,600 --> 02:29:47,840 METHODS. 3603 02:29:47,840 --> 02:29:48,920 FINALLY MORPHOLOGIC MRI CAN BE 3604 02:29:48,920 --> 02:29:51,320 USED TO GENERATE 3D MODELS OF 3605 02:29:51,320 --> 02:29:53,960 THE JOINT TO PERFORM SHAPE AND 3606 02:29:53,960 --> 02:29:56,040 TOPOLOGY ASSESSMENT OR TO 3607 02:29:56,040 --> 02:29:57,760 EVALUATE JOINT BIOMECHANICS, AND 3608 02:29:57,760 --> 02:30:02,480 THIS IS IMPORTANT BECAUSE JOINT 3609 02:30:02,480 --> 02:30:06,960 DISEASE INVOLVE THE WHOLE JOINT. 3610 02:30:06,960 --> 02:30:09,360 QUANTITATIVE MAPS OF PHYSICAL 3611 02:30:09,360 --> 02:30:11,000 PARAMETERS SUCH AS RELAXATION 3612 02:30:11,000 --> 02:30:15,480 TIMES CAN ASSESS UNDERLYING 3613 02:30:15,480 --> 02:30:16,800 BIOLOGICAL CHANGES, MODEL-BASED 3614 02:30:16,800 --> 02:30:18,120 TECHNIQUES HAVE ENABLED RAPID 3615 02:30:18,120 --> 02:30:20,200 AND RELIABLE ACQUISITION OF 3616 02:30:20,200 --> 02:30:21,520 MULTIPLE COMPLEMENTARY 3617 02:30:21,520 --> 02:30:22,520 QUANTITATIVE MR PARAMETERS. 3618 02:30:22,520 --> 02:30:24,040 AND AUTOMATIC PROS EGGS POOP 3619 02:30:24,040 --> 02:30:26,320 LINES MAKE CLINICAL TRANSLATION 3620 02:30:26,320 --> 02:30:27,960 OF QUANTITATIVE COMPOSITIONAL 3621 02:30:27,960 --> 02:30:37,920 MRI A MORE TANGIBLE GOAL AND 3622 02:30:37,920 --> 02:30:39,240 QUANTITATIVE INFORMATION 3623 02:30:39,240 --> 02:30:44,280 EXTRACTED CAN BE COMBINED WITH 3624 02:30:44,280 --> 02:30:46,240 QUANTITATIVE MRI. 3625 02:30:46,240 --> 02:30:47,800 I WILL ACKNOWLEDGE MY RESEARCH 3626 02:30:47,800 --> 02:30:48,880 SUPPORT, SOME OF MY 3627 02:30:48,880 --> 02:30:50,640 COLLABORATORS, AND THANK YOU FOR 3628 02:30:50,640 --> 02:30:53,400 YOUR KIND ATTENTION. 3629 02:30:53,400 --> 02:30:54,880 3630 02:30:54,880 --> 02:30:57,640 >>THANK YOU. 3631 02:30:57,640 --> 02:31:04,880 DR. PEDOIA, THE FLOOR IS YOURS. 3632 02:31:04,880 --> 02:31:06,800 3633 02:31:06,800 --> 02:31:10,920 >>YOU SHOULD BE ABLE TO SEE MY 3634 02:31:10,920 --> 02:31:12,320 SCREEN, NOT MY SLIDES YET, BUT 3635 02:31:12,320 --> 02:31:13,320 IN A SECOND. 3636 02:31:13,320 --> 02:31:15,160 NOW YOU SHOULD SEE MY SLIDES AND 3637 02:31:15,160 --> 02:31:15,920 HEAR ME. 3638 02:31:15,920 --> 02:31:19,080 THANK YOU FOR THE INVITATION TO 3639 02:31:19,080 --> 02:31:20,040 TALK TODAY. 3640 02:31:20,040 --> 02:31:23,800 I'M GOING TO ALSO TALK ABOUT 3641 02:31:23,800 --> 02:31:27,400 QUANTITATIVE MRI, APPLICATION TO 3642 02:31:27,400 --> 02:31:29,720 KNEE OSTEOARTHRITIS, IN 3643 02:31:29,720 --> 02:31:31,800 PARTICULAR HOW MODERN TECHNOLOGY 3644 02:31:31,800 --> 02:31:33,400 AND MACHINE LEARNING CAN HELP 3645 02:31:33,400 --> 02:31:37,560 ADDRESS SOME OF THE PROBLEMS 3646 02:31:37,560 --> 02:31:40,360 THAT RICCARDO SHOWED IN THE 3647 02:31:40,360 --> 02:31:44,720 PREVIOUS TALK. 3648 02:31:44,720 --> 02:31:49,960 AND I'LL START WITH A LITTLE BIT 3649 02:31:49,960 --> 02:31:51,760 OF INTRODUCTION ON 3650 02:31:51,760 --> 02:31:53,400 OSTEOARTHRITIS, WE ALL KNOW THE 3651 02:31:53,400 --> 02:31:57,360 PATHOGENESIS IS STILL LARGELY 3652 02:31:57,360 --> 02:31:57,640 UNKNOWN. 3653 02:31:57,640 --> 02:32:00,920 THERE ARE FEW THINGS WE KNOW, 3654 02:32:00,920 --> 02:32:05,080 CARTILAGE CHANGES AT EARLY 3655 02:32:05,080 --> 02:32:05,840 STAGES, INCLUDING HYDRATION, 3656 02:32:05,840 --> 02:32:07,280 DESTRUCTION OF COLLAGEN, AND 3657 02:32:07,280 --> 02:32:11,880 THIS PROCESS CAN BE PROBED USING 3658 02:32:11,880 --> 02:32:13,880 QUANTITATIVE MRI TECHNIQUE, ONE 3659 02:32:13,880 --> 02:32:15,480 IS T2 RELAXATION TIMES. 3660 02:32:15,480 --> 02:32:17,040 THERE ARE SEVERAL OTHERS BUT 3661 02:32:17,040 --> 02:32:19,840 THIS IS ONE THAT PROBED THE 3662 02:32:19,840 --> 02:32:20,760 COLLAGEN MATRIX OF THE 3663 02:32:20,760 --> 02:32:21,400 CARTILAGE. 3664 02:32:21,400 --> 02:32:26,480 WE KNOW IN THE LATER STAGE WE 3665 02:32:26,480 --> 02:32:30,600 OBSERVE DEHYDRATION, LOSS OF 3666 02:32:30,600 --> 02:32:35,040 CARTILAGE, MRI SCAN IS HIGH 3667 02:32:35,040 --> 02:32:36,640 RESOLUTION, HIGHLY RELIABLE 3668 02:32:36,640 --> 02:32:38,200 QUANTIFIABLE FROM AN MR, WHILE 3669 02:32:38,200 --> 02:32:45,280 THIS HAPPENS AT THE CARTILAGE 3670 02:32:45,280 --> 02:32:46,920 LEVEL WE MODELING ALSO MAKES 3671 02:32:46,920 --> 02:32:48,480 BONE SHAPE AN IMPORTANT MARKER 3672 02:32:48,480 --> 02:32:50,440 TO COMPLETE THE WHOLE JOINT 3673 02:32:50,440 --> 02:32:51,960 DISEASE PICTURE. 3674 02:32:51,960 --> 02:32:54,720 THOSE CHANGES ARE ALL 3675 02:32:54,720 --> 02:32:55,480 INTERCONNECTED AND THE 3676 02:32:55,480 --> 02:32:58,320 MECHANISTIC RELATIONSHIP ARE NOT 3677 02:32:58,320 --> 02:32:59,760 WELL MODELED YET. 3678 02:32:59,760 --> 02:33:02,040 AS WELL THE RELATIONSHIP WITH 3679 02:33:02,040 --> 02:33:03,000 CHRONIC PAIN. 3680 02:33:03,000 --> 02:33:05,880 AND IF THOSE ARE ALL VERY 3681 02:33:05,880 --> 02:33:13,520 EXPENSIVE MARKERS, LONG SCAN 3682 02:33:13,520 --> 02:33:14,840 TIME, VERY INTENSIVE 3683 02:33:14,840 --> 02:33:17,320 POST-PROCESSING, IT'S DIFFICULT 3684 02:33:17,320 --> 02:33:18,120 TO JUSTIFY CLINICAL TRANSLATION 3685 02:33:18,120 --> 02:33:21,400 EVEN IF THE SCAN TIME GETS 3686 02:33:21,400 --> 02:33:23,600 SHORTER, EVEN IF THE PROCESSING 3687 02:33:23,600 --> 02:33:25,320 GETS FULLY AUTOMATIC. 3688 02:33:25,320 --> 02:33:28,320 AND DURING THIS TALK I'LL TRY TO 3689 02:33:28,320 --> 02:33:31,560 DRAW A PICTURE ON HOW MACHINE 3690 02:33:31,560 --> 02:33:34,200 LEARNING CAN HELP IN MAKING THIS 3691 02:33:34,200 --> 02:33:37,760 CLOSER TO ACTUAL TRANSLATION, 3692 02:33:37,760 --> 02:33:43,080 USABLE FOR PATIENT MANAGEMENT. 3693 02:33:43,080 --> 02:33:45,400 DEFINITELY FIRST APPLICATION IS 3694 02:33:45,400 --> 02:33:51,640 AUTOMATIC SEGMENTATION, AS WE 3695 02:33:51,640 --> 02:33:53,520 SAID THE PROBLEM ON TOP OF LONG 3696 02:33:53,520 --> 02:33:57,320 SCAN TIME THESE MAPS NEED TO BE 3697 02:33:57,320 --> 02:34:03,360 PROCESSED, SEG MEN TAIGS -- 3698 02:34:03,360 --> 02:34:07,400 SEGMENTATION IS THE FIRST STEP. 3699 02:34:07,400 --> 02:34:16,920 SINCE 2017 GOING ON, TO DEFINE 3700 02:34:16,920 --> 02:34:19,680 SEGMENTATION, WELL TRANSLATABLE 3701 02:34:19,680 --> 02:34:21,680 AND WELL PERFORMED ON SEVERAL 3702 02:34:21,680 --> 02:34:22,080 TISSUE. 3703 02:34:22,080 --> 02:34:23,560 IN PARTICULAR, IF ACQUISITION IS 3704 02:34:23,560 --> 02:34:30,720 STANDARDIZED, 3705 02:34:30,720 --> 02:34:32,920 STANDARDIZED, IN THIS CASE WE 3706 02:34:32,920 --> 02:34:38,360 CAN DEVELOP AUTOMATIC PROCESSING 3707 02:34:38,360 --> 02:34:40,720 USING CONVOLUTION, 100% 3708 02:34:40,720 --> 02:34:42,560 INTERCHANGEABLE WITH HUMAN 3709 02:34:42,560 --> 02:34:43,200 PROCESSES. 3710 02:34:43,200 --> 02:34:44,200 WE COULD OBTAIN 3D THICKNESS 3711 02:34:44,200 --> 02:34:48,240 MAP, THIS IS ONE PATIENT ON THE 3712 02:34:48,240 --> 02:34:49,040 OSTEOARTHRITIS INITIATIVE IN 3713 02:34:49,040 --> 02:34:50,760 JUST A MATTER OF SECONDS, 3714 02:34:50,760 --> 02:34:54,200 EXACTLY AS I CAN OBTAIN THIS ONE 3715 02:34:54,200 --> 02:34:56,160 I CAN OBTAIN 45,000 THICKNESS 3716 02:34:56,160 --> 02:34:57,880 MAPS YOU'LL OBTAIN ON THE 3717 02:34:57,880 --> 02:34:59,400 OSTEOARTHRITIS INITIATIVE WITH 3718 02:34:59,400 --> 02:35:00,360 TEN YEARS OF FOLLOW-UP. 3719 02:35:00,360 --> 02:35:04,440 AND IF YOU LOOK AT THIS MAP YOU 3720 02:35:04,440 --> 02:35:05,640 WILL APPRECIATE THE INFORMATION 3721 02:35:05,640 --> 02:35:09,240 IN THE THICKNESS MAP, THIS IS 3722 02:35:09,240 --> 02:35:10,080 TRUE FOR THICKNESS, T2 3723 02:35:10,080 --> 02:35:12,560 RELAXATION TIMES, MOST OF THE 3724 02:35:12,560 --> 02:35:13,760 QUANTITATIVE MARKERS. 3725 02:35:13,760 --> 02:35:16,480 BUT WE WANT A WAY TO AGGREGATE 3726 02:35:16,480 --> 02:35:19,000 THIS INFORMATION IN A WAY THAT 3727 02:35:19,000 --> 02:35:21,280 IS TRACTABLE, USEFUL FOR 3728 02:35:21,280 --> 02:35:22,800 POPULATION ANALYSIS, AND WE WANT 3729 02:35:22,800 --> 02:35:23,920 TO HAVE EITHER A SINGLE NUMBER 3730 02:35:23,920 --> 02:35:27,200 OR SET OF NUMBERS THAT CAN 3731 02:35:27,200 --> 02:35:29,360 DESCRIBE THE STATUS OF THIS 3732 02:35:29,360 --> 02:35:30,080 CARTILAGE. 3733 02:35:30,080 --> 02:35:33,400 WHAT'S DONE IS TO DEFINE REGION 3734 02:35:33,400 --> 02:35:34,680 OF INTEREST, BASED ON ANATOMY, 3735 02:35:34,680 --> 02:35:41,040 BAGSED ON WHAT -- BASED ON 3736 02:35:41,040 --> 02:35:42,360 BIOMECHANIC, MEDIAL SIDE, 3737 02:35:42,360 --> 02:35:44,760 LATERAL SIDE, WEIGHT BEARING, 3738 02:35:44,760 --> 02:35:47,600 AND TAKE AVERAGES OF THIS 3739 02:35:47,600 --> 02:35:48,040 COMPARTMENT. 3740 02:35:48,040 --> 02:35:49,360 THIS DOESN'T SOUND NEARLY CLOSE 3741 02:35:49,360 --> 02:35:52,000 TO WHAT WE SHOULD DO CONSIDERING 3742 02:35:52,000 --> 02:35:54,720 THE RICHNESS OF INFORMATION IN 3743 02:35:54,720 --> 02:35:56,800 THIS MAP, AND ALSO HOW MUCH WORK 3744 02:35:56,800 --> 02:36:00,280 WAS DONE TO TRY TO GET A PERFECT 3745 02:36:00,280 --> 02:36:04,120 SEG 3746 02:36:04,120 --> 02:36:06,320 SEGMENTATION, AT ANY VOXEL, 3747 02:36:06,320 --> 02:36:07,880 OBTAIN HIGH RESOLUTION IMAGE TO 3748 02:36:07,880 --> 02:36:09,400 DESCRIBE THE RICHNESS OF 3749 02:36:09,400 --> 02:36:12,240 INFORMATION WITH SIX NUMBERS 3750 02:36:12,240 --> 02:36:15,760 THAT COMES WITH AVERAGE. 3751 02:36:15,760 --> 02:36:18,480 LIKELY FOR US, DESIGNED TO SOLVE 3752 02:36:18,480 --> 02:36:20,120 EXACTLY THIS PROBLEM, DESIGNED 3753 02:36:20,120 --> 02:36:21,680 TO AGGREGATE THE INFORMATION IN 3754 02:36:21,680 --> 02:36:24,400 THE BEST POSSIBLE WAY TO TRY TO 3755 02:36:24,400 --> 02:36:27,680 SOLVE A SPECIFIC TASK, 3756 02:36:27,680 --> 02:36:29,120 SUPERVISION OF CONVOLUTION IS 3757 02:36:29,120 --> 02:36:30,880 EXACTLY IN EXTRACTING THE 3758 02:36:30,880 --> 02:36:31,640 FEATURE, LEARNING THE FEATURES 3759 02:36:31,640 --> 02:36:34,680 THAT BETTER DESCRIBE A CERTAIN 3760 02:36:34,680 --> 02:36:35,560 PROCESS. 3761 02:36:35,560 --> 02:36:39,960 AND WITH THIS IN MIND, WE COULD 3762 02:36:39,960 --> 02:36:42,320 ASK A CONVOLUTION TO AGGREGATE 3763 02:36:42,320 --> 02:36:45,760 INSTEAD OF DECIDING A PRIORI THE 3764 02:36:45,760 --> 02:36:48,840 BEST BIOMARKER IS IN A CERTAIN 3765 02:36:48,840 --> 02:36:53,320 COMPARTMENT OR ANY OTHER 3766 02:36:53,320 --> 02:36:53,760 PRE-DEFINED MARKER. 3767 02:36:53,760 --> 02:36:56,240 THIS IS TRUE FOR ALL THE 3768 02:36:56,240 --> 02:36:58,800 BIOMARKERS THAT I SHOULD USE, 3769 02:36:58,800 --> 02:37:00,280 WITH THAT WE TRIED WITH A 3770 02:37:00,280 --> 02:37:04,040 PROJECT THAT WE RUN A COUPLE 3771 02:37:04,040 --> 02:37:06,080 YEARS AGO TO USE CONVOLUTION 3772 02:37:06,080 --> 02:37:08,440 BIOMARKER DISCOVERY AND DISCOVER 3773 02:37:08,440 --> 02:37:10,480 BETTER WAYS OF AGGREGATING 3774 02:37:10,480 --> 02:37:10,760 INFORMATION. 3775 02:37:10,760 --> 02:37:16,200 A LITTLE BIT OF TECHNICAL NOTE, 3776 02:37:16,200 --> 02:37:17,840 THOSE MAPS NOT EXACTLY SONG THAT 3777 02:37:17,840 --> 02:37:22,320 IS EASY TO BE HANDLED IN A 3778 02:37:22,320 --> 02:37:24,400 CLASSICAL CONVOLUTION, BECAUSE 3779 02:37:24,400 --> 02:37:28,440 BOTH SHAPE IS 3D SURFACE, 3780 02:37:28,440 --> 02:37:30,080 THICKNESS IS ALSO MATCHED WITH 3781 02:37:30,080 --> 02:37:31,800 VALUES ASSOCIATED WITH THICKNESS 3782 02:37:31,800 --> 02:37:34,360 ON SURFACE OF THE CARTILAGE, AND 3783 02:37:34,360 --> 02:37:36,440 T2 RELAXATION TIMES IS 3D VOLUME 3784 02:37:36,440 --> 02:37:39,400 THAT CAN BE TRANSLATED TO A 3785 02:37:39,400 --> 02:37:44,000 MATCH WITH PROJECTION ON 3786 02:37:44,000 --> 02:37:47,120 ARTICULAR SURFACE, TO BETTER 3787 02:37:47,120 --> 02:37:49,320 WORK ON 2D IMAGES, WE USE 3788 02:37:49,320 --> 02:37:53,000 ENCODING BY GOING IN THE CENTER 3789 02:37:53,000 --> 02:37:55,560 OF THE BONE, IN THIS CASE FEMUR 3790 02:37:55,560 --> 02:37:59,360 BUT WORKS FOR THE HIP AND 3791 02:37:59,360 --> 02:38:01,320 ANYTHING THAT HAS SPHERICALL 3792 02:38:01,320 --> 02:38:09,520 TOPOLOGY AND UNWRAP 3793 02:38:09,520 --> 02:38:13,560 OBTAIN 2 DIMENSIONAL MAPPING, X 3794 02:38:13,560 --> 02:38:15,000 AND Y, SPHERICAL ENCODING, THE 3795 02:38:15,000 --> 02:38:17,440 VALUE IS THE DISTANCE FROM THE 3796 02:38:17,440 --> 02:38:18,960 CENTROID FROM BONE SHAPE, VALUE 3797 02:38:18,960 --> 02:38:20,520 OF THICKNESS AT THAT POINT AND 3798 02:38:20,520 --> 02:38:22,920 VALUE OF T2. 3799 02:38:22,920 --> 02:38:29,160 WITH THAT WE OBTAIN AN IMAGE IN 3800 02:38:29,160 --> 02:38:30,680 WHICH EACH SINGLE 3801 02:38:30,680 --> 02:38:31,560 (INDISCERNIBLE) LOAD THICKNESS 3802 02:38:31,560 --> 02:38:33,160 AND T2 DESCRIBED IN THIS 3803 02:38:33,160 --> 02:38:35,600 PARTICULAR POINT, WHAT IS THE 3804 02:38:35,600 --> 02:38:41,040 SHAPE OF THE BONE, WHAT IS THE 3805 02:38:41,040 --> 02:38:42,600 THICKNESS AND T2 RELAXATION MAP. 3806 02:38:42,600 --> 02:38:47,200 CAN I DO ANYTHING BETTER THAN 3807 02:38:47,200 --> 02:38:49,920 WHAT AVERAGE BIOMARKER WILL DO, 3808 02:38:49,920 --> 02:38:51,360 TRYING PREDICT CHRONIC PAIN? 3809 02:38:51,360 --> 02:38:55,800 AND WE USE DATA FROM THE 3810 02:38:55,800 --> 02:38:57,400 OSTEOARTHRITIS INITIATIVE, 3811 02:38:57,400 --> 02:38:58,800 SELECTED 7,000 PARTICIPANTS. 3812 02:38:58,800 --> 02:39:01,320 WE DEFINE CHRONIC PAIN AS 3813 02:39:01,320 --> 02:39:04,560 REPORTED KNEE PAIN FOR MORE THAN 3814 02:39:04,560 --> 02:39:07,000 50 DAYS OF THE MONTH FOR MORE 3815 02:39:07,000 --> 02:39:11,920 THAN SIX MONTHS, WE EXCLUDED 3816 02:39:11,920 --> 02:39:15,960 WIDESPREAD BRAIN SYNDROME AND WE 3817 02:39:15,960 --> 02:39:19,880 MATCHED SUBJECTS FOR NO PAIN. 3818 02:39:19,880 --> 02:39:26,520 AND WE USE THIS TRIPLET AND ALL 3819 02:39:26,520 --> 02:39:28,920 THE COMBINATION OF BIOMARKERS. 3820 02:39:28,920 --> 02:39:31,880 THIS IS THE SENSITIVITY 3821 02:39:31,880 --> 02:39:36,200 SPECIFICITY OF THIS MODEL, SO 3822 02:39:36,200 --> 02:39:38,040 UNSEEN IMAGE, A COUPLE THINGS TO 3823 02:39:38,040 --> 02:39:39,560 REPORT THE INTERACTION OF THE 3824 02:39:39,560 --> 02:39:41,160 BIOMARKERS, SO WHEN I USE THE 3825 02:39:41,160 --> 02:39:43,880 THREE BIOMARKERS TOGETHER, IS 3826 02:39:43,880 --> 02:39:46,400 WHEN I ACTUALLY MAXIMIZE 3827 02:39:46,400 --> 02:39:47,840 SENSITIVITY AND SPECIFICITY AND 3828 02:39:47,840 --> 02:39:49,480 AUC OF THIS MARKER, AND WITHIN 3829 02:39:49,480 --> 02:39:53,680 DIFFERENT BIOMARKERS WHEN I USE 3830 02:39:53,680 --> 02:39:57,280 SINGLE PLANE CARTILAGE T2 BETTER 3831 02:39:57,280 --> 02:39:57,640 EXPLAINS BETTER. 3832 02:39:57,640 --> 02:39:59,680 WHAT I WANT TO DO IS DISCOVER 3833 02:39:59,680 --> 02:40:01,000 THE BIOMARKER, NOT REALLY JUST 3834 02:40:01,000 --> 02:40:04,560 TO HAVE A MODEL THAT PREDICT 3835 02:40:04,560 --> 02:40:04,920 CHRONIC PAIN. 3836 02:40:04,920 --> 02:40:09,360 AND BECAUSE OF THAT WE USE 3837 02:40:09,360 --> 02:40:13,680 GRADIENT CLASS ACTIVATION MAP. 3838 02:40:13,680 --> 02:40:14,920 THIS IS PROPAGATION TECHNIQUE 3839 02:40:14,920 --> 02:40:16,200 IDENTIFY PIXEL MORE IMPORTANT 3840 02:40:16,200 --> 02:40:18,880 FOR THE MODEL TO TAKE THE 3841 02:40:18,880 --> 02:40:20,080 DECISION ON WHERE -- TAKE THE 3842 02:40:20,080 --> 02:40:24,000 DECISION ON THE PATIENT TO BE IN 3843 02:40:24,000 --> 02:40:26,640 PAIN OR NOT IN PAIN, AND SO WE 3844 02:40:26,640 --> 02:40:29,840 THE WAY IT WORKS WE PASS THROUGH 3845 02:40:29,840 --> 02:40:34,520 EACH SUBJECT TO OUR MODELING, WE 3846 02:40:34,520 --> 02:40:36,520 OBTAIN PROBABILITY MAP, THAT IS 3847 02:40:36,520 --> 02:40:39,440 TELLING US IF THAT PIXEL IS 3848 02:40:39,440 --> 02:40:42,640 IMPORTANT OR THAT -- I SHOULD 3849 02:40:42,640 --> 02:40:44,480 SAY THAT VERTEX ON THE SURFACE 3850 02:40:44,480 --> 02:40:46,160 IS IMPORTANT OR NOT FOR THE 3851 02:40:46,160 --> 02:40:47,560 MODEL TO TAKE THE DECISION IF 3852 02:40:47,560 --> 02:40:49,000 THIS PATIENT IS IN PAIN OR IS 3853 02:40:49,000 --> 02:40:50,400 NOT IN PAIN. 3854 02:40:50,400 --> 02:40:52,600 EVERYTHING WE DID ON ENCODING IS 3855 02:40:52,600 --> 02:40:55,360 INVERTIBLE, WE CAN GO BACK ON 3856 02:40:55,360 --> 02:40:56,440 THE SURFACE. 3857 02:40:56,440 --> 02:40:57,960 AND THOSE MAPS ARE DIFFERENT FOR 3858 02:40:57,960 --> 02:40:58,960 EACH PATIENT. 3859 02:40:58,960 --> 02:41:03,320 SO EACH PATIENT HAS HIS OWN 3860 02:41:03,320 --> 02:41:07,920 DIFFERENT CLASS ACTIVATION MAP, 3861 02:41:07,920 --> 02:41:09,680 WE CAN RELUCE IN THE SAME SPACE, 3862 02:41:09,680 --> 02:41:12,720 AND WE CAN DIVIDE THEM IN TWO 3863 02:41:12,720 --> 02:41:14,040 GROUPS, TRUE POSITIVE, THROWS 3864 02:41:14,040 --> 02:41:15,800 SUBJECTS IN PAIN AND MODEL 3865 02:41:15,800 --> 02:41:17,760 CORRECTLY CLASSIFIED THEM TO BE 3866 02:41:17,760 --> 02:41:20,880 IN PAIN, AND THERE I SHOULD FIND 3867 02:41:20,880 --> 02:41:21,840 THE FEATURES THAT ARE SENSITIVE 3868 02:41:21,840 --> 02:41:23,720 FOR THE PRESENCE OF PAIN. 3869 02:41:23,720 --> 02:41:26,200 AND THE TRUE NEGATIVE CASES, AND 3870 02:41:26,200 --> 02:41:29,400 ALL THOSE CASES ARE NOT IN PAIN, 3871 02:41:29,400 --> 02:41:30,200 MODEL CORRECTLY CLASSIFYING THEM 3872 02:41:30,200 --> 02:41:32,400 TO NOT BE IN PAIN. 3873 02:41:32,400 --> 02:41:34,120 THERE I SHOULD FIND THE FEATURES 3874 02:41:34,120 --> 02:41:37,080 THAT ARE SPECIFIC FOR THE 3875 02:41:37,080 --> 02:41:38,080 ABSENCE OF PAIN. 3876 02:41:38,080 --> 02:41:41,400 AND THOSE ARE SOME OF THE 3877 02:41:41,400 --> 02:41:44,960 RESULTS ON OUR ENTIRE TEST SET, 3878 02:41:44,960 --> 02:41:46,560 AND DIVIDED BY THE DIFFERENT 3879 02:41:46,560 --> 02:41:49,280 BIOMARKER, AND IF YOU LOOK AT 3880 02:41:49,280 --> 02:41:52,760 BONE SHAPE THIS IS THE SIMPLEST 3881 02:41:52,760 --> 02:41:55,680 OF THE SITUATION, SO THE MODEL 3882 02:41:55,680 --> 02:41:57,800 IS LOOKING IN SPECIFIC LOCATION 3883 02:41:57,800 --> 02:42:00,880 TO ASSIGN THE PRESENCE OF PAIN 3884 02:42:00,880 --> 02:42:02,840 AND ABSENCE OF PAIN, SO THAT 3885 02:42:02,840 --> 02:42:04,040 IS -- WE CAN INTERPRET THE 3886 02:42:04,040 --> 02:42:05,880 EXPRESSION OF A CERTAIN FEATURE 3887 02:42:05,880 --> 02:42:09,160 IN PARTICULAR IN THE LATERAL 3888 02:42:09,160 --> 02:42:10,680 SIDE IN THE TROCHLEA, 3889 02:42:10,680 --> 02:42:11,600 PARTICULARLY IMPORTANT FOR BONE 3890 02:42:11,600 --> 02:42:12,800 SHAPE, IDENTIFIED THIS PATIENT 3891 02:42:12,800 --> 02:42:17,480 IS IN PAIN, NOT IN PAIN, BUT FOR 3892 02:42:17,480 --> 02:42:18,280 BOTH THE CARTILAGE BIOMARKER, 3893 02:42:18,280 --> 02:42:20,120 THE DISTRIBUTION OF THE FEATURES 3894 02:42:20,120 --> 02:42:21,680 THAT ARE SENSITIVE FOR PAIN ARE 3895 02:42:21,680 --> 02:42:23,640 DIFFERENT THAN THE FEATURES THAT 3896 02:42:23,640 --> 02:42:25,960 ARE SPECIFIC FOR PAIN SO THAT 3897 02:42:25,960 --> 02:42:27,560 MEANS IF YOU HAVE CERTAIN 3898 02:42:27,560 --> 02:42:30,760 FEATURE IN THE MEDIAL WEIGHT 3899 02:42:30,760 --> 02:42:33,480 BEARING REGION, THE MODEL WILL 3900 02:42:33,480 --> 02:42:34,440 HIGHLY CONFIDENCE SAY THIS 3901 02:42:34,440 --> 02:42:36,040 PATIENT IS IN PAIN BUT WITH 3902 02:42:36,040 --> 02:42:38,240 OTHER FEATURE IN THE LATERAL 3903 02:42:38,240 --> 02:42:41,400 SIDE IN THE TROCHLEA WILL VERY 3904 02:42:41,400 --> 02:42:43,280 WELL CONFIDENT SAY IT IS NO 3905 02:42:43,280 --> 02:42:43,480 PAIN. 3906 02:42:43,480 --> 02:42:45,880 IT'S NOT EASY TO JUST GET A 3907 02:42:45,880 --> 02:42:47,320 SIMPLE AVERAGE THAT THEN 3908 02:42:47,320 --> 02:42:48,080 CORRELATES WITH PAIN. 3909 02:42:48,080 --> 02:42:49,520 BUT WITH ALL THAT I DIDN'T 3910 02:42:49,520 --> 02:42:50,640 REALLY SOLVE MY PROBLEM. 3911 02:42:50,640 --> 02:42:52,120 I STILL HAVE THIS MAP. 3912 02:42:52,120 --> 02:42:55,280 BUT WHAT I HAVE NOW IS I CAN 3913 02:42:55,280 --> 02:42:58,240 INFER THIS MODEL ON ANY NEW 3914 02:42:58,240 --> 02:42:59,680 PATIENT AND HAVE A CLASS 3915 02:42:59,680 --> 02:43:02,520 ACTIVATION MAP THAT TELL ME WHAT 3916 02:43:02,520 --> 02:43:04,000 THE MODEL WOULD LOOK, WHERE THE 3917 02:43:04,000 --> 02:43:05,160 MODEL WOULD LOOK TO CLASSIFY 3918 02:43:05,160 --> 02:43:07,840 THIS PATIENT AS IN PAIN OR NOT 3919 02:43:07,840 --> 02:43:09,840 AND VERY SIMPLY CAN JUST TAKE A 3920 02:43:09,840 --> 02:43:11,600 WEIGHTED AVERAGE INSTEAD OF A 3921 02:43:11,600 --> 02:43:14,800 SINGLE AVERAGE OF A CERTAIN 3922 02:43:14,800 --> 02:43:16,840 QUANTITATIVE MRI TECHNIQUE, AND 3923 02:43:16,840 --> 02:43:19,920 GET POSSIBLY A MARKER THAT IS 3924 02:43:19,920 --> 02:43:21,800 SIMPLE AGAIN BECAUSE NOW I HAVE 3925 02:43:21,800 --> 02:43:26,560 A SINGLE NUMBER, CAN USE THE 3926 02:43:26,560 --> 02:43:28,800 OUTCOME FOR CLINICAL TRIAL, BUT 3927 02:43:28,800 --> 02:43:33,360 SPECIFICALLY PRECISE FOR THE MAP 3928 02:43:33,360 --> 02:43:34,000 OF THIS PATIENT. 3929 02:43:34,000 --> 02:43:40,480 >>A MINUTE OR TWO. 3930 02:43:40,480 --> 02:43:43,880 >>WE COMPARE THE RESULTS IN 3931 02:43:43,880 --> 02:43:46,080 REGRESSING PRESENCE OF PAIN, 3932 02:43:46,080 --> 02:43:49,160 CLASSICAL METHOD VERSUS WHAT WE 3933 02:43:49,160 --> 02:43:51,000 CALL DL-GUIDED THICKNESS MAP AND 3934 02:43:51,000 --> 02:43:52,880 ASSOCIATION WITH PAIN IS MUCH 3935 02:43:52,880 --> 02:43:53,160 STRONGER. 3936 02:43:53,160 --> 02:43:55,080 THOSE ARE DATA THAT ARE NOT SEEN 3937 02:43:55,080 --> 02:43:57,520 IN ANY CLASS OF THE TRAINING OF 3938 02:43:57,520 --> 02:43:58,320 THIS MODEL. 3939 02:43:58,320 --> 02:44:04,280 WHAT I PRESENTED IS JUST FOR THE 3940 02:44:04,280 --> 02:44:05,920 FEMUR FOR SIMPLICITY BUT 3941 02:44:05,920 --> 02:44:07,560 EVERYTHING TRANSLATE FOR TBI, 3942 02:44:07,560 --> 02:44:09,400 PATELLA, WE HAVE EXAMPLE ON THE 3943 02:44:09,400 --> 02:44:11,040 HIP AS WELL. 3944 02:44:11,040 --> 02:44:14,120 IN CONCLUSION, WHAT I HOPE I 3945 02:44:14,120 --> 02:44:17,560 SHOW TODAY THAT MACHINE LEARNING 3946 02:44:17,560 --> 02:44:20,240 CAN SERVE US AS A WAY TO 3947 02:44:20,240 --> 02:44:23,080 AUTOMATE THE PROCESS, TO BETTER 3948 02:44:23,080 --> 02:44:24,720 AGGREGATE THE INFORMATION, AND 3949 02:44:24,720 --> 02:44:26,560 TO DISCOVER NEW WAY OF 3950 02:44:26,560 --> 02:44:29,440 AGGREGATING THE INFORMATION THAT 3951 02:44:29,440 --> 02:44:32,480 ARE MORE PRECISE AND TAILOR 3952 02:44:32,480 --> 02:44:35,760 AROUND THE CHARACTERISTIC OF 3953 02:44:35,760 --> 02:44:39,280 EACH SINGLE PATIENT INSTEAD OF 3954 02:44:39,280 --> 02:44:41,600 GENERAL FEATURES LIKE AVERAGES 3955 02:44:41,600 --> 02:44:42,560 AND CERTAIN COMPARTMENT THAT ARE 3956 02:44:42,560 --> 02:44:44,200 CORRECT IN GENERAL BUT NOT 3957 02:44:44,200 --> 02:44:46,040 PRECISE ON THE SINGLE PATIENT. 3958 02:44:46,040 --> 02:44:49,360 THIS IS THE WORK OF A LOT OF 3959 02:44:49,360 --> 02:44:53,200 PEOPLE AT THE CENTER IMAGING AT 3960 02:44:53,200 --> 02:44:59,760 UCSF, IN PARTICULAR THIS PERSON 3961 02:44:59,760 --> 02:45:00,720 HERE, ALEJANDRO MORALES, MY 3962 02:45:00,720 --> 02:45:02,320 Ph.D. STUDENT A COUPLE YEARS 3963 02:45:02,320 --> 02:45:04,920 AGO, NOW HAVING FUN IN AMAZON, 3964 02:45:04,920 --> 02:45:06,200 THE MAIN PERSON THAT DEVELOPED 3965 02:45:06,200 --> 02:45:08,240 THIS PROJECT. 3966 02:45:08,240 --> 02:45:10,520 AND THANK YOU VERY MUCH FOR YOUR 3967 02:45:10,520 --> 02:45:10,760 ATTENTION. 3968 02:45:10,760 --> 02:45:13,040 >>THANK YOU. 3969 02:45:13,040 --> 02:45:15,520 NEXT WE HAVE DR. KOCH. 3970 02:45:15,520 --> 02:45:26,040 >>I'LL SHARE MY SCREEN HERE. 3971 02:45:31,800 --> 02:45:33,920 THANK FOUR THE OPPORTUNITY TO 3972 02:45:33,920 --> 02:45:35,320 PARTICIPATE IN THIS SYMPOSIUM. 3973 02:45:35,320 --> 02:45:37,000 OUR PROJECT IS LOOKING TO 3974 02:45:37,000 --> 02:45:40,720 DEVELOP MRI PROFILES OF CARPAL 3975 02:45:40,720 --> 02:45:41,800 BONE MOVEMENTS, LOOKING TO 3976 02:45:41,800 --> 02:45:44,960 DEVELOP A TOOL THAT WOULD BE 3977 02:45:44,960 --> 02:45:46,880 CAPABLE OF STUDYING COMPLEX 3978 02:45:46,880 --> 02:45:48,200 BIOMEDICAL NETWORK IN THE WRIST. 3979 02:45:48,200 --> 02:45:50,120 YOU CAN SEE FROM THE FIGURE 3980 02:45:50,120 --> 02:45:51,800 EXTRACTED FROM REVIEW ARTICLE ON 3981 02:45:51,800 --> 02:45:53,840 DIAGNOSTIC IMAGING THE WRIST, 3982 02:45:53,840 --> 02:45:55,480 THE WRIST IS AN INTRICATE 3983 02:45:55,480 --> 02:45:59,200 NETWORK OF BONES AND LIGAMENTS, 3984 02:45:59,200 --> 02:46:06,640 COMPLEX CONNECTED PROFILE OF 3985 02:46:06,640 --> 02:46:07,000 CARPAL DYNAMICS. 3986 02:46:07,000 --> 02:46:08,520 CHARACTERIZED BY DISTURBANCE IN 3987 02:46:08,520 --> 02:46:09,280 ALIGNMENT AND COORDINATED 3988 02:46:09,280 --> 02:46:10,800 MOVEMENT OF BONES AND LIGAMENTS 3989 02:46:10,800 --> 02:46:11,800 IN THE WRIST. 3990 02:46:11,800 --> 02:46:14,960 THE OVERARCHING GOAL OF OUR 3991 02:46:14,960 --> 02:46:16,720 DYNAMIC WRIST IMAGING PROGRAM TO 3992 02:46:16,720 --> 02:46:22,200 DEVELOP DIAGNOSTIC TOOLS TO 3993 02:46:22,200 --> 02:46:22,800 QUANTITY INTERCARPAL BONE 3994 02:46:22,800 --> 02:46:24,280 DYNAMICS TO VERY MANY A TOOL 3995 02:46:24,280 --> 02:46:34,000 USED TO ASSESS, TREAT, MONITOR 3996 02:46:34,000 --> 02:46:36,760 CARPAL INSTABILITY. 3997 02:46:36,760 --> 02:46:39,280 CARPAL IMAGE CAN IDENTIFY IN 3998 02:46:39,280 --> 02:46:41,120 DIFFERENT WRIST POSITIONS. 3999 02:46:41,120 --> 02:46:42,920 SUSPECTED SOURCES OF LIGAMENT 4000 02:46:42,920 --> 02:46:47,560 DAMAGE CAN BE VISUALIZED ON 4001 02:46:47,560 --> 02:46:50,960 STATIC MRI. 4002 02:46:50,960 --> 02:46:54,680 HOWEVER, LONG AGO REALIZED 4003 02:46:54,680 --> 02:46:56,880 LIMITED IN ABILITY IN CAUSE AND 4004 02:46:56,880 --> 02:46:57,320 EFFECTS. 4005 02:46:57,320 --> 02:47:00,160 OVER 40 YEARS AGO CLINICIANS 4006 02:47:00,160 --> 02:47:00,680 STARTED EXPERIMENTING WITH 4007 02:47:00,680 --> 02:47:02,480 DYNAMIC IMAGING AS A DIAGNOSTIC 4008 02:47:02,480 --> 02:47:05,080 TOOL FOR CARPAL INSTABILITY. 4009 02:47:05,080 --> 02:47:07,480 THE ONLY TECHNOLOGY AVAILABLE AT 4010 02:47:07,480 --> 02:47:10,880 THAT TIME WAS X-RAY, IN CASE 4011 02:47:10,880 --> 02:47:13,600 REPORTS THAT APPROACH PINPOINTED 4012 02:47:13,600 --> 02:47:15,560 SPECIFIC CARPAL BONE MOVEMENTS 4013 02:47:15,560 --> 02:47:20,760 THAT CAUSED INSTABILITY 4014 02:47:20,760 --> 02:47:21,000 SYMPTOMS. 4015 02:47:21,000 --> 02:47:23,440 UNFORTUNATELY, 2D IMAGING IS 4016 02:47:23,440 --> 02:47:25,560 LIMITED, THEREFORE OVER 20 YEARS 4017 02:47:25,560 --> 02:47:28,560 AGO CRISCO AND WOLFE BEGAN USING 4018 02:47:28,560 --> 02:47:30,960 DYNAMIC CT TO PERFORM VOLUMETRIC 4019 02:47:30,960 --> 02:47:33,280 DYNAMIC ANALYSES OF CARPAL 4020 02:47:33,280 --> 02:47:33,480 BONES. 4021 02:47:33,480 --> 02:47:40,240 ENSUING DECADES THAT HAS GIVEN 4022 02:47:40,240 --> 02:47:41,480 US INSIGHT. 4023 02:47:41,480 --> 02:47:42,560 QUANTIFIABLE TRACKING AND 4024 02:47:42,560 --> 02:47:44,000 PROFILING OF CARPAL BONE MOTION 4025 02:47:44,000 --> 02:47:46,080 HAS BEEN DEMONSTRATED WITHIN 4026 02:47:46,080 --> 02:47:47,600 THESE PREVIOUS CT STUDIES. 4027 02:47:47,600 --> 02:47:51,960 AND EXPANDING UPON THIS WORK OUR 4028 02:47:51,960 --> 02:47:55,720 DYNAMIC IMAGING HAS TWO GOALS, 4029 02:47:55,720 --> 02:47:58,440 FIRST TO USE 4D MRI INSTEAD OF 4030 02:47:58,440 --> 02:48:01,200 CT, MOST PATIENTS WILL UNDERGO A 4031 02:48:01,200 --> 02:48:05,880 CLINICAL MR EXAM, IN ADDITION MR 4032 02:48:05,880 --> 02:48:10,600 IS A NON-IONIZING FORM OF 4033 02:48:10,600 --> 02:48:12,640 IMAGING, FACILITATING EASIER 4034 02:48:12,640 --> 02:48:16,720 STUDIES, USED FOR LONGITUDINAL 4035 02:48:16,720 --> 02:48:17,040 ASSESSMENTS. 4036 02:48:17,040 --> 02:48:18,800 OUR TEAM DEVELOPED AND APPLIED 4037 02:48:18,800 --> 02:48:20,240 DYNAMIC MR APPROACH FOR 4038 02:48:20,240 --> 02:48:21,120 CHARACTERIZING CARPAL BONE 4039 02:48:21,120 --> 02:48:23,200 MOTION THAT COULD BE INTEGRATED 4040 02:48:23,200 --> 02:48:24,840 INTO EXISTING CLINICAL 4041 02:48:24,840 --> 02:48:26,920 DIAGNOSTIC IMAGING WORK FLOWS, 4042 02:48:26,920 --> 02:48:31,560 IN THAT STUDY DEMONSTRATED THAT 4043 02:48:31,560 --> 02:48:32,080 HEALTHY PATHOLOGIC WRIST 4044 02:48:32,080 --> 02:48:34,000 KINEMATIC PROFILES EXIST AND CAN 4045 02:48:34,000 --> 02:48:36,200 BE DETECTED USING THIS APPROACH. 4046 02:48:36,200 --> 02:48:39,800 TODAY TO DATE OUR EXEMPTS HAVE 4047 02:48:39,800 --> 02:48:43,320 BEEN DONE AT THREE TESLA USING 4048 02:48:43,320 --> 02:48:44,440 THE ACQUISITION POSITIONING 4049 02:48:44,440 --> 02:48:48,880 SHOWN IN THIS IMAGE. 4050 02:48:48,880 --> 02:48:49,800 SUBJECT'S ARMS FIXED WITH 4051 02:48:49,800 --> 02:48:52,640 PADDING, LARGE COIL TO GIVE 4052 02:48:52,640 --> 02:48:54,520 RANGE OF MOTION FOR MOVEMENT WE 4053 02:48:54,520 --> 02:48:56,920 ANALYZED IN OUR WORK. 4054 02:48:56,920 --> 02:49:00,400 NO PHYSICAL MOTION CONSTRAINTS 4055 02:49:00,400 --> 02:49:01,200 ARE UTILIZED. 4056 02:49:01,200 --> 02:49:03,040 WE DO GIVE PARTICIPANTS A VIDEO 4057 02:49:03,040 --> 02:49:04,800 WHICH YOU SEE HERE TO GUIDE 4058 02:49:04,800 --> 02:49:05,680 THEIR MOTION AND PACE THEM. 4059 02:49:05,680 --> 02:49:07,800 YOU CAN SEE THE MOTION IS PRETTY 4060 02:49:07,800 --> 02:49:08,880 SLOW. 4061 02:49:08,880 --> 02:49:09,960 THIS IS REALLY IMPORTANT TO GIVE 4062 02:49:09,960 --> 02:49:13,800 SUBJECTS A SENSE OF HOW FAST TO 4063 02:49:13,800 --> 02:49:14,640 MOVE. 4064 02:49:14,640 --> 02:49:18,080 OUR STATIC AND DYNAMIC IMAGES 4065 02:49:18,080 --> 02:49:23,440 USE A 2-POINT SEQUENCE, TO GIVE 4066 02:49:23,440 --> 02:49:24,640 GOOD CONTRAST TO THE BONES. 4067 02:49:24,640 --> 02:49:26,920 I'LL TALK ABOUT WHY THAT'S 4068 02:49:26,920 --> 02:49:27,200 IMPORTANT. 4069 02:49:27,200 --> 02:49:29,040 WE COLLECT 40 DYNAMIC VOLUMES 4070 02:49:29,040 --> 02:49:30,440 FOR EACH MOTION. 4071 02:49:30,440 --> 02:49:34,360 SUBJECT IS VISUALLY CUED TO MAKE 4072 02:49:34,360 --> 02:49:37,160 THREE CYCLES, INDICATED MOTION 4073 02:49:37,160 --> 02:49:37,680 DIRECTION WITHIN 90-SECOND 4074 02:49:37,680 --> 02:49:39,560 ACQUISITION, AND HERE YOU CAN 4075 02:49:39,560 --> 02:49:41,680 SEE A SINGLE SLICE CAPTURED 4076 02:49:41,680 --> 02:49:44,960 THROUGH A FULL DEVIATION MOTION 4077 02:49:44,960 --> 02:49:47,360 CYCLE, BUT THESE ARE 3D VOLUMES 4078 02:49:47,360 --> 02:49:48,120 THAT WERE ACQUIRED. 4079 02:49:48,120 --> 02:49:50,440 THIS IS JUST A SINGLE SLICE 4080 02:49:50,440 --> 02:49:51,720 THROUGH THE VOLUMES. 4081 02:49:51,720 --> 02:49:53,400 BASIC APPROACH FOR OUR CARPAL 4082 02:49:53,400 --> 02:49:59,080 BONE TRACKING IS SIMPLE IN 4083 02:49:59,080 --> 02:49:59,280 CONCEPT. 4084 02:49:59,280 --> 02:50:00,840 WE SEGMENT BONES. 4085 02:50:00,840 --> 02:50:02,880 USING A 3D NEURAL NETWORK, 4086 02:50:02,880 --> 02:50:04,000 IMPORTANT TO MAKE THIS VIABLE 4087 02:50:04,000 --> 02:50:07,520 AND NOT HAVE PEOPLE SPENDING 4088 02:50:07,520 --> 02:50:08,720 DAYS SEGMENTING INDIVIDUAL BONES 4089 02:50:08,720 --> 02:50:10,000 THROUGH THE MULTIPLE VOLUMES 4090 02:50:10,000 --> 02:50:12,320 THAT ARE COLLECTED. 4091 02:50:12,320 --> 02:50:14,400 WE THEN REGISTER THE BONES TO A 4092 02:50:14,400 --> 02:50:16,800 STATIC REFERENCE SO WE TAKE 4093 02:50:16,800 --> 02:50:18,400 DYNAMIC VOLUMES AND REGISTER TO 4094 02:50:18,400 --> 02:50:18,840 STATICS. 4095 02:50:18,840 --> 02:50:20,840 AND WE DO THAT THROUGH A POINT 4096 02:50:20,840 --> 02:50:21,960 CLOUD SYSTEM. 4097 02:50:21,960 --> 02:50:28,080 WE ALSO CONSTRUCT A RADIAL 4098 02:50:28,080 --> 02:50:29,200 SYSTEM IN THE WRIST. 4099 02:50:29,200 --> 02:50:33,080 SO IN THE END, WHAT THAT GIVES 4100 02:50:33,080 --> 02:50:37,080 US IS A REFERENCED SET OF CARPAL 4101 02:50:37,080 --> 02:50:38,600 BONE MOTIONS AND MOVEMENTS WITH 4102 02:50:38,600 --> 02:50:43,840 6 DEGREES OF FREEDOM IN A RADIAL 4103 02:50:43,840 --> 02:50:45,800 CORONET SYSTEM CONSISTENT ACROSS 4104 02:50:45,800 --> 02:50:48,120 EACH SUBJECTING. 4105 02:50:48,120 --> 02:50:54,480 WE CAN TRACK THREE TARGET BONES, 4106 02:50:54,480 --> 02:50:56,120 FOR TWO BASIC MOTIONS WE'RE 4107 02:50:56,120 --> 02:50:59,040 INVESTIGATING NOW. 4108 02:50:59,040 --> 02:51:00,400 WE AUTOMATICALLY DETECT THE 4109 02:51:00,400 --> 02:51:01,840 INDEPENDENT SEPARATE MOTION 4110 02:51:01,840 --> 02:51:04,440 CYCLE DOMAINS, SHOWN HERE IN THE 4111 02:51:04,440 --> 02:51:07,040 COLORS HERE, AND THAT ALLOWS US 4112 02:51:07,040 --> 02:51:09,240 TO LOOK AT REPEAT MEASURES IN 4113 02:51:09,240 --> 02:51:10,120 EACH SUBJECT. 4114 02:51:10,120 --> 02:51:12,240 WE BASICALLY GET THREE CYCLES OF 4115 02:51:12,240 --> 02:51:14,800 MOTION FOR ALL OF THESE METRICS 4116 02:51:14,800 --> 02:51:17,760 THAT WE'RE CAPTURING. 4117 02:51:17,760 --> 02:51:21,360 IT'S BEEN ESTABLISHED THE 4118 02:51:21,360 --> 02:51:25,400 CAPITATE AND THIRD MET A CAR MAL 4119 02:51:25,400 --> 02:51:27,200 BONE MOVE SYNCHRONOUSLY, THIS 4120 02:51:27,200 --> 02:51:32,440 GIVES A MECHANISM FOR 4121 02:51:32,440 --> 02:51:33,000 SELF-REFERENCE ANALYSIS. 4122 02:51:33,000 --> 02:51:36,280 WE USED THIS IN TRACKING 4123 02:51:36,280 --> 02:51:36,680 METHODOLOGY. 4124 02:51:36,680 --> 02:51:38,760 WE LOOKED AT ALL OF OUR METRICS 4125 02:51:38,760 --> 02:51:41,320 THIS WAY AND FOUND THAT MOST OF 4126 02:51:41,320 --> 02:51:46,240 THOSE DEGREES OF FREEDOM METRICS 4127 02:51:46,240 --> 02:51:47,760 SHOWED A LOWER BEHAVIOR, IN THE 4128 02:51:47,760 --> 02:51:49,960 PLOTS SHOWING A SUBSET OF 4129 02:51:49,960 --> 02:51:51,240 COHORT, EACH SUBJECT REPRESENTED 4130 02:51:51,240 --> 02:51:53,240 BY DIFFERENT COLOR. 4131 02:51:53,240 --> 02:51:56,080 YOU CAN SEE CLEAR POLYNOMIAL 4132 02:51:56,080 --> 02:51:57,080 TRENDS OF INDIVIDUAL SUBJECT 4133 02:51:57,080 --> 02:51:58,400 PLOTS HERE. 4134 02:51:58,400 --> 02:52:03,520 WE USED THIS TO DERIVE BATTERY 4135 02:52:03,520 --> 02:52:07,560 ACROSS MOTION, BONES, KINEMATIC 4136 02:52:07,560 --> 02:52:08,240 PARAMETERS. 4137 02:52:08,240 --> 02:52:09,480 SEPARATELY LINEAR AND QUADRATIC 4138 02:52:09,480 --> 02:52:11,200 FITS PERFORMED FOR EACH MOTION, 4139 02:52:11,200 --> 02:52:13,480 WE INDICATE AS PATH. 4140 02:52:13,480 --> 02:52:16,320 WE SEE EXPECT THE VARIANCES IN 4141 02:52:16,320 --> 02:52:17,240 PATHWAYS, ANTICIPATED AND 4142 02:52:17,240 --> 02:52:18,960 ULTIMATELY THE REASON WE COLLECT 4143 02:52:18,960 --> 02:52:20,840 MULTIPLE CYCLES OF MOTION IN 4144 02:52:20,840 --> 02:52:22,960 EACH EXPERIMENT. 4145 02:52:22,960 --> 02:52:25,360 AND THIS APPROACH GIVES US 120 4146 02:52:25,360 --> 02:52:27,560 TOTAL CHARACTERISTICS MOTION 4147 02:52:27,560 --> 02:52:31,600 METRICS FOR EACH SUBJECT. 4148 02:52:31,600 --> 02:52:34,200 OUR INITIAL EXPLORATORY STUDIES 4149 02:52:34,200 --> 02:52:35,840 USING THIS APPROACH COLLECTED 4150 02:52:35,840 --> 02:52:38,720 DATA ON 49 SUBJECTS, 20 HAD A 4151 02:52:38,720 --> 02:52:39,840 HISTORY OF WRIST INJURY, 29 NO 4152 02:52:39,840 --> 02:52:42,760 HISTORY OF INJURY OR SYMPTOMS. 4153 02:52:42,760 --> 02:52:46,680 IMAGED DOMINANT HAND IN 4154 02:52:46,680 --> 02:52:48,960 ASYMPTOMATIC, INJURED HAND IN 4155 02:52:48,960 --> 02:52:50,760 INJURED CO-HURT, 29 RECRUITED TO 4156 02:52:50,760 --> 02:52:53,360 SAYS STABILITY OF DYNAMIC MR 4157 02:52:53,360 --> 02:52:53,640 METRICS. 4158 02:52:53,640 --> 02:52:54,920 BECAUSE OF THE HIGHLY 4159 02:52:54,920 --> 02:52:56,440 EXPLORATORY NATURE OF THE STUDY 4160 02:52:56,440 --> 02:53:00,280 THE INJURED COHORT WAS RECRUITED 4161 02:53:00,280 --> 02:53:01,960 OVER SEVERAL MONTHS, BROADLY 4162 02:53:01,960 --> 02:53:04,000 RECRUITED BUT BASED ON A 4163 02:53:04,000 --> 02:53:07,080 SELF-REPORTED HISTORY OF PRIOR 4164 02:53:07,080 --> 02:53:07,400 INJURY. 4165 02:53:07,400 --> 02:53:08,720 INITIAL GOAL TO EXPLORE GROUP 4166 02:53:08,720 --> 02:53:09,880 CHANGES BETWEEN THE SUBJECTS 4167 02:53:09,880 --> 02:53:11,560 WITHOUT HISTORY OF INJURY AND 4168 02:53:11,560 --> 02:53:14,920 THOSE WITH HISTORY OF TRAUMA. 4169 02:53:14,920 --> 02:53:18,040 OUR INITIAL ANALYSIS LOOKED AT 4170 02:53:18,040 --> 02:53:20,200 CONSISTENCY OF METRICS ACROSS 4171 02:53:20,200 --> 02:53:26,520 THE FULL COHORT, 17 HAD ICC 4172 02:53:26,520 --> 02:53:30,160 VALUES GREATER THAN 7, 4173 02:53:30,160 --> 02:53:31,600 MODERATELY CONSISTENT WITHIN 4174 02:53:31,600 --> 02:53:32,360 SUBJECTS. 4175 02:53:32,360 --> 02:53:33,920 IMPORTANCE OF THIS INTRASUBJECT 4176 02:53:33,920 --> 02:53:35,880 STABILITY IS INTERESTING GIVEN 4177 02:53:35,880 --> 02:53:38,000 PERCEIVED ABUNDANCE OF WITHIN 4178 02:53:38,000 --> 02:53:39,800 SUBJECT INSTABILITY ACROSS THE 4179 02:53:39,800 --> 02:53:40,040 METRICS. 4180 02:53:40,040 --> 02:53:42,440 HOWEVER, WE DON'T REALLY FULLY 4181 02:53:42,440 --> 02:53:44,440 UNDERSTAND THE IMPACT OF HOW 4182 02:53:44,440 --> 02:53:45,200 PATHOLOGY OR INJURY INDUCED 4183 02:53:45,200 --> 02:53:48,040 CHANGES ARE GOING TO IMPACT 4184 02:53:48,040 --> 02:53:50,240 THESE METRICS, WE STILL DON'T 4185 02:53:50,240 --> 02:53:53,080 UNDERSTAND HOW THIS INTRASUBJECT 4186 02:53:53,080 --> 02:53:54,280 STABILITY FACTORS INTO THINGS. 4187 02:53:54,280 --> 02:53:57,880 TO START LOOKING AT THE METRIC 4188 02:53:57,880 --> 02:54:00,720 CONSISTENCY ACROSS THE COHORTS 4189 02:54:00,720 --> 02:54:02,360 WE USED ICC, LOOKED ACROSS 4190 02:54:02,360 --> 02:54:04,040 SUBJECTS WITHIN THOSE SPECIFIC 4191 02:54:04,040 --> 02:54:05,000 INJURY COHORTS. 4192 02:54:05,000 --> 02:54:08,400 AND IF WE LOOK AT DISTRIBUTION 4193 02:54:08,400 --> 02:54:10,600 YOU CAN SEE IMPORTANT TRENDS 4194 02:54:10,600 --> 02:54:13,520 HERE. 4195 02:54:13,520 --> 02:54:14,600 BASICALLY WE FOUND THAT THE 4196 02:54:14,600 --> 02:54:16,800 INJURED SUBJECTS HAD A LOT MORE 4197 02:54:16,800 --> 02:54:18,440 VARIATION IN THEIR METRICS, AND 4198 02:54:18,440 --> 02:54:20,200 THAT THE SUBJECTS WITHOUT A 4199 02:54:20,200 --> 02:54:21,640 HISTORY OF INJURY WERE MUCH MORE 4200 02:54:21,640 --> 02:54:21,920 STABLE. 4201 02:54:21,920 --> 02:54:24,480 AND WE REALLY ONLY SAW THAT THE 4202 02:54:24,480 --> 02:54:26,080 HIGHER LEVELS OF CONSISTENCY IN 4203 02:54:26,080 --> 02:54:28,400 METRICS, THAT TOLD US THAT THE 4204 02:54:28,400 --> 02:54:30,480 DYSFUNCTION WAS ADDING SOME 4205 02:54:30,480 --> 02:54:31,280 INSTABILITY INTO OUR METRICS, 4206 02:54:31,280 --> 02:54:33,360 WHICH WAS A GOOD PRELIMINARY 4207 02:54:33,360 --> 02:54:33,560 SIGN. 4208 02:54:33,560 --> 02:54:36,080 WE ALSO PERFORMED PRELIMINARY 4209 02:54:36,080 --> 02:54:38,840 ANALYSES OF THESE DYNAMIC 4210 02:54:38,840 --> 02:54:39,840 MEASURES AGAINST RADIOLOGY 4211 02:54:39,840 --> 02:54:40,440 IDENTIFYING LIGAMENT AND 4212 02:54:40,440 --> 02:54:48,600 CARTILAGE DONE ON A SUBSET OF 4213 02:54:48,600 --> 02:54:56,120 OUR STUDY COHORTS USING CLINICAL 4214 02:54:56,120 --> 02:55:00,480 STATIC MRI, ON 20 SUBJECTS. 4215 02:55:00,480 --> 02:55:01,920 ASSESSED POTENTIAL COVARIATE 4216 02:55:01,920 --> 02:55:05,120 IMPACT OF CARTILAGE DAMAGE, SIX 4217 02:55:05,120 --> 02:55:07,080 KEY ZONES, CLASSIFIED. 4218 02:55:07,080 --> 02:55:09,240 IMAGES SHOWN HERE FROM OUR STUDY 4219 02:55:09,240 --> 02:55:11,760 COHORT DEMONSTRATING HOW STATIC 4220 02:55:11,760 --> 02:55:15,040 CLINICAL MR USED TO IDENTIFY 4221 02:55:15,040 --> 02:55:16,600 PATHOLOGY INCLUDING TEARS, 4222 02:55:16,600 --> 02:55:18,000 ABSORPTIONS, ABSENCE OF 4223 02:55:18,000 --> 02:55:20,520 LIGAMENTS, AND THE DEGENERATION 4224 02:55:20,520 --> 02:55:24,920 THAT MANIFESTED AS PLASTIC 4225 02:55:24,920 --> 02:55:25,240 DEFORMATION. 4226 02:55:25,240 --> 02:55:27,240 THE ULTIMATE GOAL TO BUILD 4227 02:55:27,240 --> 02:55:28,880 MODELS THAT USED MULTIPLE 4228 02:55:28,880 --> 02:55:31,400 METRICS TO MODEL COMPLEX 4229 02:55:31,400 --> 02:55:33,320 INSTABILITY, HIGHLY ANATOMIC 4230 02:55:33,320 --> 02:55:35,680 SOURCES OF INSTABILITY, AS A 4231 02:55:35,680 --> 02:55:36,240 PRELIMINARY TEST PERFORMED 4232 02:55:36,240 --> 02:55:39,200 INDIVIDUAL CORRELATION TESTS OF 4233 02:55:39,200 --> 02:55:40,720 METRICS AGAINST RADIOLOGY, 4234 02:55:40,720 --> 02:55:42,520 PATHOLOGY CLASSIFICATIONS OF 4235 02:55:42,520 --> 02:55:42,760 LIGAMENTS. 4236 02:55:42,760 --> 02:55:45,360 TO REDUCE TESTS FOR EACH WE 4237 02:55:45,360 --> 02:55:47,520 REDUCED TEST OF MOST STABLE 4238 02:55:47,520 --> 02:55:51,560 WITHIN A SUBCOHORT WITH MINIMAL 4239 02:55:51,560 --> 02:55:52,640 DAMAGE TO CARPAL LIGAMENT OR 4240 02:55:52,640 --> 02:55:54,280 CARTILAGE, 30 OF THEM WERE FOUND 4241 02:55:54,280 --> 02:56:00,200 TO BE SIGNIFICANT WITH P-VALUES 4242 02:56:00,200 --> 02:56:03,800 LESS THAN .05, THREE WERE BELOW 4243 02:56:03,800 --> 02:56:07,720 OR CLOSE TO SIGNIFICANCE LEVEL. 4244 02:56:07,720 --> 02:56:09,600 ALL THREE OBSERVATIONS PROVIDE 4245 02:56:09,600 --> 02:56:11,800 CONNECTION BETWEEN DYNAMIC MR 4246 02:56:11,800 --> 02:56:13,640 METRICS AND LIGAMENT DAMAGE 4247 02:56:13,640 --> 02:56:14,200 CLASSIFICATIONS. 4248 02:56:14,200 --> 02:56:23,360 STRONGEST CORRELATION WAS 4249 02:56:23,360 --> 02:56:25,400 RELATED TO SCAPHOID POSITION, 4250 02:56:25,400 --> 02:56:26,720 PROVIDING ENCOURAGEMENT THESE 4251 02:56:26,720 --> 02:56:28,480 DYNAMIC MR MEASURES ARE 4252 02:56:28,480 --> 02:56:32,000 INDICATIVE OF UNDERLYING CARPAL 4253 02:56:32,000 --> 02:56:32,240 PATHOLOGY. 4254 02:56:32,240 --> 02:56:33,640 >>A MINUTE LEFT. 4255 02:56:33,640 --> 02:56:33,840 >>OKAY. 4256 02:56:33,840 --> 02:56:36,680 COMING TO THE END. 4257 02:56:36,680 --> 02:56:37,800 WE PERFORMED A PRELIMINARY 4258 02:56:37,800 --> 02:56:40,080 INVESTIGATION INTO USE OF 4259 02:56:40,080 --> 02:56:45,040 DYNAMIC MR TO MODEL DIAGNOSTIC 4260 02:56:45,040 --> 02:56:45,680 PATHOLOGY. 4261 02:56:45,680 --> 02:56:46,680 WE UTILIZE STANDARDIZED 4262 02:56:46,680 --> 02:56:52,840 REGRESSION AND IN THE END WE 4263 02:56:52,840 --> 02:56:59,280 FOUND THAT WE GOT LIGAMENT 4264 02:56:59,280 --> 02:57:07,600 DAMAGE WITH AUC OF .79, THIS 4265 02:57:07,600 --> 02:57:09,600 SUBJECT HAD CONFIRMED SCAPHOID 4266 02:57:09,600 --> 02:57:11,960 TEAR, WHERE DO WE GO FROM HERE? 4267 02:57:11,960 --> 02:57:15,840 WE KNOW MR CAN BE USED TO 4268 02:57:15,840 --> 02:57:19,880 COLLECT DYNAMIC 3D IMAGES AND 4269 02:57:19,880 --> 02:57:23,800 TRACK BASIC WRIST MOTIONS, 4270 02:57:23,800 --> 02:57:26,200 DEVELOPED A MECHANISM TO COMPARE 4271 02:57:26,200 --> 02:57:28,600 METRICS ACROSS COHORTS, FUNCTION 4272 02:57:28,600 --> 02:57:31,240 OF SYMPTOMS FOR PATHOLOGICAL 4273 02:57:31,240 --> 02:57:31,600 CLASSIFICATIONS. 4274 02:57:31,600 --> 02:57:33,240 PRELIMINARY ANALYSIS USED THOSE 4275 02:57:33,240 --> 02:57:36,520 METRICS, SHOWN LINK BETWEEN THE 4276 02:57:36,520 --> 02:57:38,360 DYNAMIC TO RELEVANT MEASURES OF 4277 02:57:38,360 --> 02:57:38,720 WRIST DAMAGE. 4278 02:57:38,720 --> 02:57:39,920 NOW WE'RE POISED TO ASK 4279 02:57:39,920 --> 02:57:41,480 IMPORTANT QUESTIONS ABOUT THE 4280 02:57:41,480 --> 02:57:43,080 UTILITY OF THOSE METRICS, 4281 02:57:43,080 --> 02:57:44,840 SPECIFICALLY ARE THE METRICS 4282 02:57:44,840 --> 02:57:47,360 MORE SPECIFIC TO SENSITIVE 4283 02:57:47,360 --> 02:57:48,320 INJURIES, AND INSTABILITY, 4284 02:57:48,320 --> 02:57:50,120 PARTICULARLY RELATIVE TO 4285 02:57:50,120 --> 02:57:52,280 EXISTING STATIC IMAGING METHODS? 4286 02:57:52,280 --> 02:57:53,520 FURTHERMORE, ARE THOSE METRICS 4287 02:57:53,520 --> 02:57:59,200 CAPABLE OF IMPROVING DIAGNOSTICS 4288 02:57:59,200 --> 02:58:01,160 AND IMPROVING OUTCOMES OR 4289 02:58:01,160 --> 02:58:01,440 MONITORING. 4290 02:58:01,440 --> 02:58:03,040 I'D LIKE TO ACKNOWLEDGE MY KEY 4291 02:58:03,040 --> 02:58:04,440 COLLABORATORS AND OUR SOURCE OF 4292 02:58:04,440 --> 02:58:05,440 FUNDING FOR THE STUDY. 4293 02:58:05,440 --> 02:58:09,480 THANK YOU FOR YOUR TIME. 4294 02:58:09,480 --> 02:58:14,280 >>NEXT WE HAVE DR. YIN. 4295 02:58:14,280 --> 02:58:16,920 >>LET ME SHARE MY SCREEN. 4296 02:58:16,920 --> 02:58:18,840 I'M HOPING YOU'RE SEEING 4297 02:58:18,840 --> 02:58:19,320 PRESENTATION MODE. 4298 02:58:19,320 --> 02:58:21,600 >>YES. 4299 02:58:21,600 --> 02:58:27,520 >>THANK YOU. 4300 02:58:27,520 --> 02:58:30,200 THIS TWO DAYS HAS BEEN AMAZING 4301 02:58:30,200 --> 02:58:32,040 LEARNING EXPERIENCE FOR ME. 4302 02:58:32,040 --> 02:58:34,360 NOW I REALLY APPRECIATE THIS 4303 02:58:34,360 --> 02:58:36,880 OPPORTUNITY TO INTRODUCE THE 4304 02:58:36,880 --> 02:58:38,280 SLIP INTERFACE TECHNIQUE THAT 4305 02:58:38,280 --> 02:58:41,680 WE'VE BEEN WORKING ON WITH 4306 02:58:41,680 --> 02:58:44,520 POTENTIAL TO ASSESS MOBILITY OF 4307 02:58:44,520 --> 02:58:45,480 THE MYOFASCIAL INTERFACE. 4308 02:58:45,480 --> 02:58:47,240 AS WE LEARNED FROM THE GREAT 4309 02:58:47,240 --> 02:58:50,800 TALKS, THERE ARE MANY COMPONENT 4310 02:58:50,800 --> 02:58:52,320 CONTRIBUTING TO JOINT 4311 02:58:52,320 --> 02:58:55,920 BIOMECHANICS INCLUDING FASCIA 4312 02:58:55,920 --> 02:58:59,040 SYSTEM WHICH INCLUDES THE FIRST 4313 02:58:59,040 --> 02:59:04,080 LAYER OF LUMBAR FASCIA AND MANY 4314 02:59:04,080 --> 02:59:06,800 STRUCTURES SURROUNDING THE 4315 02:59:06,800 --> 02:59:07,920 SKELETAL MUSCLES, THE 4316 02:59:07,920 --> 02:59:10,200 INTERCONNECTED NETWORK TO 4317 02:59:10,200 --> 02:59:15,120 FACILITATE MOVEMENT AND OBTAIN 4318 02:59:15,120 --> 02:59:16,360 POSTURE. 4319 02:59:16,360 --> 02:59:18,640 IN HEALTHY STATE CAN TRANSMIT 4320 02:59:18,640 --> 02:59:20,280 FORCES FOR MOVER. 4321 02:59:20,280 --> 02:59:21,600 AND GLIDING SURFACE FOR MUSCLES 4322 02:59:21,600 --> 02:59:24,120 TO MOVE AGAINST NEIGHBORING 4323 02:59:24,120 --> 02:59:26,120 STRUCTURES, AS WE LEARNED FROM A 4324 02:59:26,120 --> 02:59:31,320 TALK THIS MORNING THIS IS DUE TO 4325 02:59:31,320 --> 02:59:34,200 NATURAL ELASTICITY AND 4326 02:59:34,200 --> 02:59:36,600 LUBRICATING OF HYALURONIC ACID 4327 02:59:36,600 --> 02:59:39,040 IN CONNECTIVE TISSUE OF THE 4328 02:59:39,040 --> 02:59:39,720 FACTOR. 4329 02:59:39,720 --> 02:59:42,320 OVERUSE, MISUSE OR INJURY COULD 4330 02:59:42,320 --> 02:59:45,360 DISRUPT AND CAUSE DEGRADE AND 4331 02:59:45,360 --> 02:59:47,840 BECOME ENTANGLED WHICH INCREASES 4332 02:59:47,840 --> 02:59:49,440 ITS VISCOSITY AND AS A RESULT 4333 02:59:49,440 --> 02:59:52,160 THE FASCIA COULD BECOME LESS 4334 02:59:52,160 --> 02:59:53,280 MOBILE AND MORE ADHESIVE. 4335 02:59:53,280 --> 02:59:56,960 SO, IF WE CAN FIND A WAY TO 4336 02:59:56,960 --> 02:59:58,480 RELIABLY MEASURE THE FASCIA 4337 02:59:58,480 --> 03:00:01,800 MOBILITY IT COULD OFFER IMAGING 4338 03:00:01,800 --> 03:00:03,240 BIOMARKER TO DIFFERENTIATE 4339 03:00:03,240 --> 03:00:04,640 BETWEEN HEALTHY FREE-MOVING 4340 03:00:04,640 --> 03:00:05,720 FASCIA AND IMPAIRED ADHESIVE 4341 03:00:05,720 --> 03:00:08,920 FASCIA IN THE PATIENT WITH 4342 03:00:08,920 --> 03:00:09,360 MYOFASCIAL PAIN. 4343 03:00:09,360 --> 03:00:14,240 AND TO ASSESS MOBILITY OF FASCIA 4344 03:00:14,240 --> 03:00:23,800 I'D LIKE TO INTRODUCE SII, MR 4345 03:00:23,800 --> 03:00:25,240 ELASTOGRAPHY MRE-BASED METHOD 4346 03:00:25,240 --> 03:00:31,680 FOR TISSUE ADHERENCE. 4347 03:00:31,680 --> 03:00:35,600 TWO ADJACENT LAYERS, VIBRATION, 4348 03:00:35,600 --> 03:00:39,320 EXHIBIT MORE MOVEMENT, WILL -- 4349 03:00:39,320 --> 03:00:42,160 CAUSING DISRUPTION ACROSS THE 4350 03:00:42,160 --> 03:00:45,040 BOUNDARY. 4351 03:00:45,040 --> 03:00:50,200 AND WE CALCULATE SHEAR STRENGTH, 4352 03:00:50,200 --> 03:00:53,240 WE NOTICE POTENTIAL VALUES OF 4353 03:00:53,240 --> 03:00:56,880 INTERFACE, MRE CALCULATED A 4354 03:00:56,880 --> 03:00:59,040 METRIC AS NORMALIZED, AND 4355 03:00:59,040 --> 03:01:03,320 ORIGINALLY DEVELOPED SI, TO 4356 03:01:03,320 --> 03:01:08,480 EXAMINE THE ADHERENCE, SHOWING 4357 03:01:08,480 --> 03:01:12,080 EXAMPLES, NON-ADHERENT HIGH NOSS 4358 03:01:12,080 --> 03:01:13,960 VALUES, BUT ADHERENT TUMORS DO 4359 03:01:13,960 --> 03:01:15,720 NOT HAVE SLIP INTERFACE. 4360 03:01:15,720 --> 03:01:17,480 WE NOTED ALL THE VIBRATIONS 4361 03:01:17,480 --> 03:01:21,640 WE'RE WORKING WITH HERE ARE IN 4362 03:01:21,640 --> 03:01:23,760 THE MICRO METER RANGE, OUR 4363 03:01:23,760 --> 03:01:25,400 TECHNIQUES ARE EXTREMELY 4364 03:01:25,400 --> 03:01:27,520 SENSITIVE TO EVEN THE SLIGHTEST 4365 03:01:27,520 --> 03:01:29,560 CHANGES IN DISPLACEMENT ACROSS 4366 03:01:29,560 --> 03:01:31,200 THE INTERFACE. 4367 03:01:31,200 --> 03:01:34,440 AND WE HAVE ALSO ADVANCED OUR 4368 03:01:34,440 --> 03:01:35,240 TECHNIQUE BY INCORPORATING 4369 03:01:35,240 --> 03:01:37,560 MACHINE LEARNING-BASED APPROACH 4370 03:01:37,560 --> 03:01:39,080 TO QUANTIFY ADHESIONS 4371 03:01:39,080 --> 03:01:40,400 AUTOMATICALLY IDENTIFIED SLIP 4372 03:01:40,400 --> 03:01:43,560 AND NON-SLIP PARTS OF INTERFACE, 4373 03:01:43,560 --> 03:01:46,920 AND EXAMPLE WE CAN CALCULATED A 4374 03:01:46,920 --> 03:01:49,480 HEARINGS PERCENTAGE OF MENINGEAL 4375 03:01:49,480 --> 03:01:52,560 MASS AND HAVE FULLY ADHERENT 4376 03:01:52,560 --> 03:01:55,400 TUMORS FROM NON-ADHERENT IN THE 4377 03:01:55,400 --> 03:01:56,560 SURGICAL EVALUATION REFERENCE 4378 03:01:56,560 --> 03:01:56,800 STANDARD. 4379 03:01:56,800 --> 03:01:59,960 EXCITING PART IS WE CAN ALSO 4380 03:01:59,960 --> 03:02:04,120 VISUALIZE TUMOR ADHESION IN 3D 4381 03:02:04,120 --> 03:02:05,120 VIEW PROVIDING NEUROSURGEONS 4382 03:02:05,120 --> 03:02:09,800 VALUABLE VISUAL GUIDE DURING 4383 03:02:09,800 --> 03:02:11,480 THEIR SURGICAL PROCEDURES. 4384 03:02:11,480 --> 03:02:13,080 SO WE STARTED THIS STUDY BY 4385 03:02:13,080 --> 03:02:17,480 ASKING WHETHER IT IS POSSIBLE TO 4386 03:02:17,480 --> 03:02:23,160 A 4387 03:02:23,160 --> 03:02:28,760 ADAPT USE SI, TO INTERFACE IN 4388 03:02:28,760 --> 03:02:30,480 HEALTHY VOLUNTEERS FIRST. 4389 03:02:30,480 --> 03:02:32,800 JUST A QUICK RUNDOWN HOW MRE 4390 03:02:32,800 --> 03:02:35,000 WORKS, IN GENERAL MRE IS BASED 4391 03:02:35,000 --> 03:02:39,240 ON THE IDEA FIRST YOU PUT 4392 03:02:39,240 --> 03:02:42,560 MECHANICAL WASTE IN, IMAGE WAYS 4393 03:02:42,560 --> 03:02:45,080 WITH MRE SEQUENCE, APPLY 4394 03:02:45,080 --> 03:02:48,760 ALGORITHM TO CALCULATE TISSUE 4395 03:02:48,760 --> 03:02:50,880 MECHANICAL PROPERTIES LIKE 4396 03:02:50,880 --> 03:02:52,520 STIFFNESS, DAMPING OR NOSSED A 4397 03:02:52,520 --> 03:02:52,800 HEARINGS. 4398 03:02:52,800 --> 03:02:56,560 THE TRICKY PART IS HOW TO 4399 03:02:56,560 --> 03:02:57,880 INTRODUCE WAYS TO ENSURE 4400 03:02:57,880 --> 03:03:00,360 PROPAGATE NOT ONLY IN TARGET 4401 03:03:00,360 --> 03:03:04,200 TISSUE BUT IN DESIGN MANNER THAT 4402 03:03:04,200 --> 03:03:05,400 ALLOWS VISUALIZE SLIP INTERFACE. 4403 03:03:05,400 --> 03:03:08,920 BY SAYING, FOR EXAMPLE, IN THE 4404 03:03:08,920 --> 03:03:11,120 FOREARM, TO KNOW WHETHER SII CAN 4405 03:03:11,120 --> 03:03:13,640 BE USED TO LOCALIZE AND 4406 03:03:13,640 --> 03:03:14,960 VISUALIZE THE FUNCTIONAL 4407 03:03:14,960 --> 03:03:15,840 COMPARTMENTS OF THE FLEXOR 4408 03:03:15,840 --> 03:03:23,880 MUSCLES OF THE HAND SUCH AS 4409 03:03:23,880 --> 03:03:29,360 FLEXOR DIGITORUM PROFUNDUS, DID 4410 03:03:29,360 --> 03:03:30,920 NOT HAVE DISTINCT COMPARTMENTS, 4411 03:03:30,920 --> 03:03:36,720 SO TO VISUALIZE IT WITH THE 4412 03:03:36,720 --> 03:03:39,560 DRUM-LIKE DRIVER TO CREATE 4413 03:03:39,560 --> 03:03:40,880 VIBRATION TO VIBRATION EACH 4414 03:03:40,880 --> 03:03:42,200 INDIVIDUAL FINGER, AND VIBRATION 4415 03:03:42,200 --> 03:03:43,520 TRAVELS THROUGH THE TENDON 4416 03:03:43,520 --> 03:03:46,600 CONNECTED TO THE FOREARM 4417 03:03:46,600 --> 03:03:47,800 MUSCLES. 4418 03:03:47,800 --> 03:03:54,240 AND YOU'RE SEEING HERE NOSS MAP 4419 03:03:54,240 --> 03:03:56,320 DURING VIBRATION OF INDEX 4420 03:03:56,320 --> 03:04:03,320 FINGER, AND MIDDLE, RING, LITTLE 4421 03:04:03,320 --> 03:04:05,160 FINGER INDIVIDUALLY VIBRATED. 4422 03:04:05,160 --> 03:04:06,080 DIFFERENT REGIONS ACTIVATE 4423 03:04:06,080 --> 03:04:07,920 ALLIANCE WITH EACH FINGER 4424 03:04:07,920 --> 03:04:08,920 FUNCTIONALITY, WE CALL IT 4425 03:04:08,920 --> 03:04:12,560 FUNCTIONAL SLIP INTERFACE. 4426 03:04:12,560 --> 03:04:18,080 WHEN THERE'S NO EXTERNAL 4427 03:04:18,080 --> 03:04:19,960 VIBRATION APPLIED, NOW VISIBLE. 4428 03:04:19,960 --> 03:04:22,640 AND MOVING TO THE LEG MUSCLE 4429 03:04:22,640 --> 03:04:26,000 LOOKING AT THE DEEP ENTER 4430 03:04:26,000 --> 03:04:31,920 MUSCULAR FASCIA, USING DIFFERENT 4431 03:04:31,920 --> 03:04:34,080 DRIVING MECHANISMS EMPLOYING 4432 03:04:34,080 --> 03:04:35,720 PNEUMATIC AROUND THE THIGH, 4433 03:04:35,720 --> 03:04:40,240 ACQUIRED WAVE, YOU CAN SEE HOW 4434 03:04:40,240 --> 03:04:44,160 WAVES UPWARD AND DOWNWARD. 4435 03:04:44,160 --> 03:04:48,320 MEMORY SCANS WITH KNEE BAND TO 4436 03:04:48,320 --> 03:04:50,200 AND LEG STRAIGHT AFFECTING 4437 03:04:50,200 --> 03:04:51,200 INTERFACE BETWEEN MUSCLES. 4438 03:04:51,200 --> 03:04:54,040 WE KNOW SOME INTERESTING 4439 03:04:54,040 --> 03:04:59,280 PATTERNS, FOR EXAMPLE, WHEN THE 4440 03:04:59,280 --> 03:05:00,920 KNEE WAS BENT, AND WITH THE 4441 03:05:00,920 --> 03:05:03,680 STRAIGHT LEG WE SAW CLEANER 4442 03:05:03,680 --> 03:05:05,200 INTERFACES THERE. 4443 03:05:05,200 --> 03:05:07,280 WE THINK THIS INTERFACE BECOMES 4444 03:05:07,280 --> 03:05:08,800 MUCH CLEARER DURING MUSCLE 4445 03:05:08,800 --> 03:05:11,960 CONTRACTION, SO, FOR EXAMPLE, IN 4446 03:05:11,960 --> 03:05:15,800 THE BENT KNEE AND KNEE FLEXOR 4447 03:05:15,800 --> 03:05:18,120 MUSCLES IN CONTRACTION BUT 4448 03:05:18,120 --> 03:05:19,400 EXTENSOR MUSCLES ARE RELAXED, 4449 03:05:19,400 --> 03:05:22,160 AND CONVERSELY WHEN KNEE IS 4450 03:05:22,160 --> 03:05:24,040 STRAIGHT THE QUADRICEPS IN 4451 03:05:24,040 --> 03:05:28,480 CONTRACTION, FROM NOSS MAPS WE 4452 03:05:28,480 --> 03:05:31,040 CAN SEE CLEARLY THE CONTRACTED 4453 03:05:31,040 --> 03:05:31,280 MUSCLES. 4454 03:05:31,280 --> 03:05:33,240 AND SIMILARLY IN THE STRAIGHT 4455 03:05:33,240 --> 03:05:36,720 LEG WHERE THE HIP JOINT EXTENDS, 4456 03:05:36,720 --> 03:05:39,800 SLOPE INTERFACE OBSERVED AROUND 4457 03:05:39,800 --> 03:05:44,720 HIP EXTENSOR MUSCLES, AND KNEE 4458 03:05:44,720 --> 03:05:46,760 RELAXATION, THE MUSCLE IN 4459 03:05:46,760 --> 03:05:49,880 QUADRICEP ACTS IN HIP FLEXOR AS 4460 03:05:49,880 --> 03:05:51,200 SLOPE INTERFACE. 4461 03:05:51,200 --> 03:05:54,720 THIS FINDINGS INDICATE S.I. HAS 4462 03:05:54,720 --> 03:05:56,600 ABILITY TO DIFFERENTIATE 4463 03:05:56,600 --> 03:05:58,680 MYOFASCIAL INTERFACE BETWEEN 4464 03:05:58,680 --> 03:05:59,600 DIFFERENT MUSCULAR STATES 4465 03:05:59,600 --> 03:06:00,640 SHOWING HOW SENSITIVE OUR 4466 03:06:00,640 --> 03:06:04,080 TECHNIQUE IS WHEN IT COMES TO 4467 03:06:04,080 --> 03:06:04,680 STUDY MUSCLES. 4468 03:06:04,680 --> 03:06:07,760 AND WHEN IT COMES TO LOWER BACK 4469 03:06:07,760 --> 03:06:10,520 WE'RE INTERESTED IN STUDY 4470 03:06:10,520 --> 03:06:11,600 INTRAMUSCULAR FASCIA INTERFACE 4471 03:06:11,600 --> 03:06:22,000 AND THORACOLUMBAR TLF. 4472 03:06:24,240 --> 03:06:26,800 WE SAW NOTHING, NOT THE SLOPE 4473 03:06:26,800 --> 03:06:28,440 INTERFACE WE WERE EXPECTING, WE 4474 03:06:28,440 --> 03:06:30,440 THINK THIS COULD BE DUE TO 4475 03:06:30,440 --> 03:06:34,560 UNIQUE CHALLENGES FOR THE LOW 4476 03:06:34,560 --> 03:06:38,640 BACK, FOR EXAMPLE THE FAT 4477 03:06:38,640 --> 03:06:39,600 SUPPRESSION CAN MAKE IT 4478 03:06:39,600 --> 03:06:41,280 DIFFICULT TO VISUALIZE THE 4479 03:06:41,280 --> 03:06:42,480 FASCIA STRUCTURES WE'RE 4480 03:06:42,480 --> 03:06:44,960 INTERESTED, AND ALSO DEEP FASCIA 4481 03:06:44,960 --> 03:06:47,560 OF THE TRUNK BEHAVIOR 4482 03:06:47,560 --> 03:06:48,720 DIFFERENTLY FROM THE LIMBS. 4483 03:06:48,720 --> 03:06:50,880 WE NEED TO TAILOR TO TRIGGER 4484 03:06:50,880 --> 03:06:52,640 RELATIVE MOTION BETWEEN THE 4485 03:06:52,640 --> 03:06:56,240 DIFFERENT FASCIAL LAYERS TO 4486 03:06:56,240 --> 03:06:59,840 VISUALIZE THE INTERFACE HERE. 4487 03:06:59,840 --> 03:07:04,440 FIRST WE DEVELOPED OUR VAST 4488 03:07:04,440 --> 03:07:05,440 ACQUISITION TECHNIQUE THAT 4489 03:07:05,440 --> 03:07:10,120 ALLOWS WATER AND FAT SIGNALS TO 4490 03:07:10,120 --> 03:07:12,440 ENHANCE, ON THE RIGHT, TO 4491 03:07:12,440 --> 03:07:13,880 ENHANCE THE CONTRAST, THE 4492 03:07:13,880 --> 03:07:15,440 SIGNALS WE COULD LIKE TO SEE 4493 03:07:15,440 --> 03:07:17,360 FROM THE FASCIA STRUCTURE. 4494 03:07:17,360 --> 03:07:21,320 ALSO GIVING LOW BACK MUSCLES THE 4495 03:07:21,320 --> 03:07:24,320 LONGITUDINALLY AND AS A MUSCLE 4496 03:07:24,320 --> 03:07:26,760 GROUPS WITH MULTIPLE MUSCLE 4497 03:07:26,760 --> 03:07:28,760 BUNDLES WITH DIFFERENT 4498 03:07:28,760 --> 03:07:32,040 ORIENTATION, EXTENSIVELY TEST 4499 03:07:32,040 --> 03:07:35,200 THE DRIVER VERSIONS AND 4500 03:07:35,200 --> 03:07:38,080 EVENTUALLY DISCOVERED A BELT 4501 03:07:38,080 --> 03:07:42,240 DRIVER WRAPPED AROUND L4/L5 DISC 4502 03:07:42,240 --> 03:07:45,640 PROVED TO BE THE MOST EFFECTIVE 4503 03:07:45,640 --> 03:07:46,040 SOLUTION. 4504 03:07:46,040 --> 03:07:51,840 AND AS A RESULT OF THIS 4505 03:07:51,840 --> 03:07:54,560 ADAPTION, IMPROVEMENT IN THE 4506 03:07:54,560 --> 03:07:56,960 ALGORITHM, WE HAVE ACHIEVED 4507 03:07:56,960 --> 03:07:57,640 POTENTIAL IMPROVEMENTS FROM 4508 03:07:57,640 --> 03:08:00,040 NOTHING TO A CLEAR DETAILED 4509 03:08:00,040 --> 03:08:03,880 DEPICTION OF THE POSTERIOR, 4510 03:08:03,880 --> 03:08:08,000 MID-ING, ANTERIOR LAYERS OF TLF 4511 03:08:08,000 --> 03:08:11,440 ASKER WITH AS OTHER 4512 03:08:11,440 --> 03:08:13,280 INTRAMUSCULAR INTERFACES. 4513 03:08:13,280 --> 03:08:15,400 IN HEALTHY VOLUNTEERS, WE DO SEE 4514 03:08:15,400 --> 03:08:17,560 THAT SUCCESS FOR ADAPTION FROM 4515 03:08:17,560 --> 03:08:20,240 THE BRAIN TO MUSCLE, VISIBILITY 4516 03:08:20,240 --> 03:08:22,920 OF VISUALIZING AND CODIFYING THE 4517 03:08:22,920 --> 03:08:28,120 MYOFASCIAL ENTER INTERFACE HAS 4518 03:08:28,120 --> 03:08:29,640 SENSITIVITY TO DIFFERENT MUSCLE 4519 03:08:29,640 --> 03:08:32,080 STATES WHICH IS GOOD, BUT ALSO 4520 03:08:32,080 --> 03:08:35,800 POSE CHALLENGES IN CONTROLLING 4521 03:08:35,800 --> 03:08:38,520 FOR VARIATIONS IN THE MUSCLE 4522 03:08:38,520 --> 03:08:39,400 STATES ACROSS THE DIFFERENT 4523 03:08:39,400 --> 03:08:42,440 HEALTHY INDIVIDUALS AND PATIENT 4524 03:08:42,440 --> 03:08:44,480 COHORTS. 4525 03:08:44,480 --> 03:08:45,240 AND THE OPTIMIZATION OF 4526 03:08:45,240 --> 03:08:47,200 COLLABORATIVE (INDISCERNIBLE) IS 4527 03:08:47,200 --> 03:08:50,680 A KEY ROLE, WORKING FURTHER WITH 4528 03:08:50,680 --> 03:08:52,080 DRIVERS, EVENTUALLY DEVELOPED 4529 03:08:52,080 --> 03:08:56,480 HIGH RESOLUTION IMAGING 4530 03:08:56,480 --> 03:08:57,480 PERFORMING TESTS SCANS TO 4531 03:08:57,480 --> 03:08:59,880 UNDERSTAND AND DO THE PILOT 4532 03:08:59,880 --> 03:09:01,400 CLINICAL SCANS WITH THE CLINICAL 4533 03:09:01,400 --> 03:09:03,240 PHYSICAL TIME FRAME. 4534 03:09:03,240 --> 03:09:05,560 WE HOPE THAT THIS COULD PAVE THE 4535 03:09:05,560 --> 03:09:09,400 WAY FOR APPLYING SII TO 4536 03:09:09,400 --> 03:09:10,160 DIFFERENTATE BETWEEN HEALTHY 4537 03:09:10,160 --> 03:09:11,680 FASCIA AND INJURED OR IMPAIRED 4538 03:09:11,680 --> 03:09:14,960 FASCIA IN PATIENTS WITH 4539 03:09:14,960 --> 03:09:15,440 MYOFASCIAL PAIN. 4540 03:09:15,440 --> 03:09:18,640 I'D LIKE TO THANK MY COLLEAGUES 4541 03:09:18,640 --> 03:09:25,280 AND THE EMORY LAB AND MY OWN 4542 03:09:25,280 --> 03:09:26,360 TEAM, ESPECIALLY THE BIOMARKER 4543 03:09:26,360 --> 03:09:30,400 PROGRAM, AND THANK YOU FOR YOUR 4544 03:09:30,400 --> 03:09:30,680 ATTENTION. 4545 03:09:30,680 --> 03:09:31,920 >>THANK YOU. 4546 03:09:31,920 --> 03:09:35,120 NOW WE MOVE INTO THE PANELIST 4547 03:09:35,120 --> 03:09:36,560 COMMENTS SECTION. 4548 03:09:36,560 --> 03:09:40,560 FIRST DR. BANKS. 4549 03:09:40,560 --> 03:09:41,360 >>GOOD AFTERNOON. 4550 03:09:41,360 --> 03:09:44,840 JUST A BRIEF INTRODUCTION, SCOTT 4551 03:09:44,840 --> 03:09:47,000 BANKS, UNIVERSITY OF FLORIDA, 4552 03:09:47,000 --> 03:09:50,560 PROFESSOR OF MECHANICAL AND 4553 03:09:50,560 --> 03:09:52,640 AEROSPACE ENGINEERING, 40 YEARS 4554 03:09:52,640 --> 03:09:54,680 WORKING WITH ORTHOPEDIC SURGEONS 4555 03:09:54,680 --> 03:09:55,880 AND MEDICAL DEVICE COMPANIES TO 4556 03:09:55,880 --> 03:10:01,800 HELP SURGEONS GET BETTER 4557 03:10:01,800 --> 03:10:05,520 RESULTS, WORK FOCUSED ON JOINT 4558 03:10:05,520 --> 03:10:07,480 ARTHROPLASTY, KNEES AND SOME 4559 03:10:07,480 --> 03:10:09,240 EXTENT SHOULDERS, THE WORK HAS 4560 03:10:09,240 --> 03:10:12,200 BEEN INVOLVING NEW IMAGING 4561 03:10:12,200 --> 03:10:15,040 TECHNIQUES, DYNAMIC FLUOROSCOPY, 4562 03:10:15,040 --> 03:10:16,480 3D MEASUREMENTS, COMPUTATIONAL 4563 03:10:16,480 --> 03:10:18,360 MODELS, A LOT OF IMPLANT DESIGN. 4564 03:10:18,360 --> 03:10:20,400 I HAVE A LOT OF RELEVANT 4565 03:10:20,400 --> 03:10:23,680 CONFLICTS IF WE TALK ABOUT JOINT 4566 03:10:23,680 --> 03:10:26,000 REPLACEMENTS. YESTERDAY THE 4567 03:10:26,000 --> 03:10:27,640 COMMENT WAS MADE KNEE 4568 03:10:27,640 --> 03:10:29,080 REPLACEMENTS ARE REALLY GOOD, 4569 03:10:29,080 --> 03:10:32,120 80% OF PEOPLE ARE PRETTY 4570 03:10:32,120 --> 03:10:32,400 SATISFIED. 4571 03:10:32,400 --> 03:10:34,640 IT'S THE 20% THAT KEEP ME UP AT 4572 03:10:34,640 --> 03:10:38,480 NIGHT, TO BE HONEST. 4573 03:10:38,480 --> 03:10:40,880 THAT'S WHAT DRIVES OUR FOCUS 4574 03:10:40,880 --> 03:10:42,840 THAT, MAKING THAT A MORE 4575 03:10:42,840 --> 03:10:44,040 REPRODUCIBLE AND BENEFICIAL 4576 03:10:44,040 --> 03:10:44,280 OUTCOME. 4577 03:10:44,280 --> 03:10:52,920 RIGHT NOW THERE'S 2 2 250,000E 4578 03:10:52,920 --> 03:10:55,640 WITH A WIDGET IN THEM OFF MY 4579 03:10:55,640 --> 03:10:57,000 DESK, I'M CONCERNED ABOUT THAT 4580 03:10:57,000 --> 03:10:57,720 COHORT. 4581 03:10:57,720 --> 03:10:59,040 I APPRECIATE THE OPPORTUNITY AS 4582 03:10:59,040 --> 03:11:03,000 A SORT OF HEAVY METAL 4583 03:11:03,000 --> 03:11:04,000 ORTHOPEDICS PERSPECTIVE TO 4584 03:11:04,000 --> 03:11:05,840 PARTICIPATE IN THIS. 4585 03:11:05,840 --> 03:11:07,720 AND I DO HAVE SOME COMMENTS AND 4586 03:11:07,720 --> 03:11:09,280 QUESTIONS WHEN WE GET TO THAT 4587 03:11:09,280 --> 03:11:11,880 WITH OUR PANEL. 4588 03:11:11,880 --> 03:11:13,400 4589 03:11:13,400 --> 03:11:16,360 >>THANK YOU. 4590 03:11:16,360 --> 03:11:16,760 DR. KOGAN? 4591 03:11:16,760 --> 03:11:17,800 >>HI. 4592 03:11:17,800 --> 03:11:21,600 THANKS FOR HAVING ME ON THE 4593 03:11:21,600 --> 03:11:22,200 PANEL. 4594 03:11:22,200 --> 03:11:27,200 I'M ASSISTANT PROFESSOR OF 4595 03:11:27,200 --> 03:11:34,440 ROILING AT STANFORD, MY FOCUS ON 4596 03:11:34,440 --> 03:11:35,400 IMAGING METHODOLOGY MRI, 4597 03:11:35,400 --> 03:11:36,320 RECENTLY PET MRI. 4598 03:11:36,320 --> 03:11:38,160 I THOUGHT TALKS WERE GREAT AND 4599 03:11:38,160 --> 03:11:39,800 LIKED THIS SESSION. 4600 03:11:39,800 --> 03:11:41,960 I WANT TO ADD TWO KEY AREAS THAT 4601 03:11:41,960 --> 03:11:43,720 I THINK WILL FOLLOW WITH WHAT WE 4602 03:11:43,720 --> 03:11:47,480 HEARD A LOT TODAY AND YESTERDAY 4603 03:11:47,480 --> 03:11:49,520 AS WELL, WHICH IS SOME FOCUS ON 4604 03:11:49,520 --> 03:11:51,720 FUNCTION AND WHOLE JOINT 4605 03:11:51,720 --> 03:11:51,960 DISEASE. 4606 03:11:51,960 --> 03:11:54,360 IMPORTANT TO NOTE MOST OF OUR 4607 03:11:54,360 --> 03:11:55,440 IMAGING METHODOLOGIES ARE 4608 03:11:55,440 --> 03:11:59,120 ACQUIRED IN A STATIC AND 4609 03:11:59,120 --> 03:11:59,560 OFTENTIMES UNLOADED 4610 03:11:59,560 --> 03:12:02,200 CONFIGURATION, AND SO THE MORE 4611 03:12:02,200 --> 03:12:07,680 WE CAN DO TO ASSESS FUNCTION 4612 03:12:07,680 --> 03:12:09,800 WITH IMAGE AING, KEVIN GAVE A 4613 03:12:09,800 --> 03:12:12,240 GREAT TALK, SORT OF HOW TISSUE 4614 03:12:12,240 --> 03:12:14,640 PROPERTIES CHANGE UNDER LOAD. 4615 03:12:14,640 --> 03:12:21,400 AND OTHER MODALITIES SUCH AS 4616 03:12:21,400 --> 03:12:23,040 DUAL CHEMICAL FLUOROSCOPY, PET 4617 03:12:23,040 --> 03:12:23,920 METHODS, SO THERE'S REALLY GOOD 4618 03:12:23,920 --> 03:12:26,200 WORK COMING OUT AND I HOPE IT 4619 03:12:26,200 --> 03:12:27,160 CONTINUES, AS WELL AS GUIDANCE 4620 03:12:27,160 --> 03:12:30,200 ON HOW THAT CAN BE USED TO 4621 03:12:30,200 --> 03:12:33,800 REALLY GUIDE CLINICAL DECISIONS. 4622 03:12:33,800 --> 03:12:35,080 THE SECOND POINT, WHOLE JOINT 4623 03:12:35,080 --> 03:12:37,280 DISEASE FOR A LONG TIME WE 4624 03:12:37,280 --> 03:12:38,040 FOCUSED ON CARTILAGE. 4625 03:12:38,040 --> 03:12:41,000 WE'VE GONE AWAY FROM THAT IN THE 4626 03:12:41,000 --> 03:12:43,480 LAST DECADE BUT CAN DO MORE. 4627 03:12:43,480 --> 03:12:45,600 WE HEARD ON THE MRI SIDE WE CAN 4628 03:12:45,600 --> 03:12:47,000 LOOK AT MULTIPLE TISSUES. 4629 03:12:47,000 --> 03:12:47,760 I'VE BEEN PARTICULARLY 4630 03:12:47,760 --> 03:12:50,200 INTERESTED IN HOW WE CAN ADD 4631 03:12:50,200 --> 03:12:52,240 MOLECULAR INFORMATION TO THAT 4632 03:12:52,240 --> 03:12:54,000 WITH PET, POSSIBILITIES TO LOOK 4633 03:12:54,000 --> 03:12:55,640 AT INFLAMMATION AND BONE 4634 03:12:55,640 --> 03:12:57,240 REMODELING WITH THE STRUCTURE 4635 03:12:57,240 --> 03:13:00,480 AND COMPOSITION WE GET WITH MRI. 4636 03:13:00,480 --> 03:13:02,240 LASTLY THE FOCUS ON PAIN, THIS 4637 03:13:02,240 --> 03:13:05,120 CAME UP A LOT YESTERDAY THAT 4638 03:13:05,120 --> 03:13:06,760 IMAGING OF STRUCTURE DOESN'T 4639 03:13:06,760 --> 03:13:08,600 REALLY CORRELATE PARTICULARLY 4640 03:13:08,600 --> 03:13:09,040 WELL WITH PAIN. 4641 03:13:09,040 --> 03:13:11,800 AND SO IF WE CAN SOMEHOW ASSESS 4642 03:13:11,800 --> 03:13:13,320 BETTER THOSE MARKERS OF PAIN TO 4643 03:13:13,320 --> 03:13:16,720 BE ABLE TO SEPARATE OUT WHAT IS 4644 03:13:16,720 --> 03:13:18,120 PAIN, WHAT IS PSYCHOSOMATIC, WHO 4645 03:13:18,120 --> 03:13:20,560 IS O.A., WHAT MAY BE SOMETHING 4646 03:13:20,560 --> 03:13:22,320 ELSE IN THE JOINT, AGAIN I THINK 4647 03:13:22,320 --> 03:13:24,720 THERE SORT OF PET IMAGING OF 4648 03:13:24,720 --> 03:13:26,720 NEUROPATHIC SOURCES OF PAIN AS 4649 03:13:26,720 --> 03:13:28,400 WELL AS NEWER TRACES THAT ARE 4650 03:13:28,400 --> 03:13:31,600 COMING OUT TO LOOK AT SPECIFIC 4651 03:13:31,600 --> 03:13:32,840 UPREGULATED PAIN RECEPTORS SUCH 4652 03:13:32,840 --> 03:13:36,200 AS SIGNAL 1 ARE PROMISING THERE. 4653 03:13:36,200 --> 03:13:38,600 4654 03:13:38,600 --> 03:13:42,560 >>THANK YOU. 4655 03:13:42,560 --> 03:13:43,080 DR. CEVIDANES. 4656 03:13:43,080 --> 03:13:46,080 >>MAY I SHARE MY SCREEN 4657 03:13:46,080 --> 03:13:46,320 BRIEFLY? 4658 03:13:46,320 --> 03:13:46,560 >>SURE. 4659 03:13:46,560 --> 03:13:50,680 >>OKAY. 4660 03:13:50,680 --> 03:13:53,400 SO JUST BRIEF BACKGROUND, I 4661 03:13:53,400 --> 03:13:55,000 THINK I'M THE ONLY DENTIST IN 4662 03:13:55,000 --> 03:13:59,200 THE PANEL, FOCUSED ON A SMALL 4663 03:13:59,200 --> 03:14:00,520 JOINT, THE TEMPOROMANDIBULAR 4664 03:14:00,520 --> 03:14:03,480 JOINT, WHICH HAS A DIFFERENT 4665 03:14:03,480 --> 03:14:13,880 PHYSIOLOGY AND ANATOMY B 4666 03:14:14,800 --> 03:14:16,960 ECAUSE -- THAN LARGER JOINTS, 4667 03:14:16,960 --> 03:14:18,440 IT'S EVEN MORE SUSCEPTIBLE FOR 4668 03:14:18,440 --> 03:14:20,640 BONE CHANGES, A GOOD MODEL TO 4669 03:14:20,640 --> 03:14:21,080 STUDY BONE CHANGES. 4670 03:14:21,080 --> 03:14:24,800 THANK YOU SO VERY MUCH FOR NIH 4671 03:14:24,800 --> 03:14:26,120 ORGANIZATION OF THIS SUPER 4672 03:14:26,120 --> 03:14:27,360 IMPORTANT SYMPOSIUM. 4673 03:14:27,360 --> 03:14:28,000 MY WORK, HOPEFULLY WHAT I CAN 4674 03:14:28,000 --> 03:14:30,400 ADD TO THE DISCUSSION IN THIS 4675 03:14:30,400 --> 03:14:32,920 PANEL, HAS FOCUSED ON 4676 03:14:32,920 --> 03:14:35,200 INTEGRATING IMAGING BIOLOGICAL 4677 03:14:35,200 --> 03:14:37,880 AND IMAGING MARKERS, WE HAVE 4678 03:14:37,880 --> 03:14:40,960 IDENTIFIED BIOMARKERS OF ADULT 4679 03:14:40,960 --> 03:14:41,920 TMJ OSTEOARTHRITIS OR 4680 03:14:41,920 --> 03:14:43,440 DEGENERATIVE JOINT DISEASE. 4681 03:14:43,440 --> 03:14:47,280 AS WELL AS WORK ON PREDICTIVE 4682 03:14:47,280 --> 03:14:49,720 MODELS OF ADULT PROGRESSION AND 4683 03:14:49,720 --> 03:14:52,640 WITH REGARD TO THAT RECENT WORK 4684 03:14:52,640 --> 03:15:03,320 HAS DEVELOPED IN ENSEMBLE MODEL, 4685 03:15:03,320 --> 03:15:05,360 TOP PERFORMING MODELS FOR 4686 03:15:05,360 --> 03:15:07,480 CROSS-VALIDATION, WHAT WE'VE 4687 03:15:07,480 --> 03:15:11,920 FOUND IS THAT THE TOP 4688 03:15:11,920 --> 03:15:13,560 CONTRIBUTING PREDICTORS OF 4689 03:15:13,560 --> 03:15:14,880 IMPROVED OR WORSE PROGNOSIS AT 4690 03:15:14,880 --> 03:15:18,520 THE CONSERVATIVE TREATMENT IN A 4691 03:15:18,520 --> 03:15:29,080 TWO-YEAR FOLLOW-UP WERE ACTUALLY 4692 03:15:30,160 --> 03:15:30,680 CO-MORBIDITS, INTERESTINGLY 4693 03:15:30,680 --> 03:15:35,880 COMORBID PAIN CONDITIONS AS WELL 4694 03:15:35,880 --> 03:15:39,520 AS MOUTH OPENING WERE AMONG TOP 4695 03:15:39,520 --> 03:15:40,400 CONTRIBUTORS, LOOK FORWARD TO 4696 03:15:40,400 --> 03:15:41,800 FURTHER DISCUSSION WITH THE 4697 03:15:41,800 --> 03:15:43,040 PANEL, WITH MY BACKGROUND. 4698 03:15:43,040 --> 03:15:49,880 THANK YOU. 4699 03:15:49,880 --> 03:15:55,600 >>THANK YOU. 4700 03:15:55,600 --> 03:15:56,200 DR. SIKDAR? 4701 03:15:56,200 --> 03:15:56,920 >>GOOD AFTERNOON. 4702 03:15:56,920 --> 03:16:00,400 THANK YOU FOR HAVING ME ON THIS 4703 03:16:00,400 --> 03:16:00,600 PANEL. 4704 03:16:00,600 --> 03:16:02,680 I'M A PROFESSOR OF 4705 03:16:02,680 --> 03:16:05,120 BIOENGINEERING, GEORGE MASON 4706 03:16:05,120 --> 03:16:07,520 UNIVERSITY. 4707 03:16:07,520 --> 03:16:11,920 I'M PART OF AN INTERDISCIPLINARY 4708 03:16:11,920 --> 03:16:12,560 GROUP, MYOFASCIAL PAIN. 4709 03:16:12,560 --> 03:16:16,360 AND THE POINT I WOULD LIKE TO 4710 03:16:16,360 --> 03:16:17,880 MAKE IS THAT WE'VE HEARD A LOT 4711 03:16:17,880 --> 03:16:21,640 ABOUT THE COMPLEXITY OF THE 4712 03:16:21,640 --> 03:16:24,600 PROBLEM FROM MULTIPLE 4713 03:16:24,600 --> 03:16:26,200 PERSPECTIVES, INCLUDING 4714 03:16:26,200 --> 03:16:26,800 BIOPSYCHOSOCIAL. 4715 03:16:26,800 --> 03:16:28,920 THE CHALLENGE FOR BIOMARKER 4716 03:16:28,920 --> 03:16:31,040 DISCOVERY IS THAT WHEN IT COMES 4717 03:16:31,040 --> 03:16:34,760 TO CHRONIC PAIN WE'RE TRYING TO 4718 03:16:34,760 --> 03:16:35,960 DIFFERENTIATE NORMAL ADAPTATION 4719 03:16:35,960 --> 03:16:37,280 VERSUS MALADAPTATION, WHOLE 4720 03:16:37,280 --> 03:16:43,840 JOINT LEVEL, PERHAPS WHOLE HUMAN 4721 03:16:43,840 --> 03:16:44,040 LEVEL. 4722 03:16:44,040 --> 03:16:44,960 LOOKING AT INDIVIDUAL 4723 03:16:44,960 --> 03:16:46,320 STRUCTURES, EVEN DYNAMICS OF 4724 03:16:46,320 --> 03:16:47,400 INDIVIDUAL STRUCTURES, ONLY 4725 03:16:47,400 --> 03:16:49,560 GIVES US A PIECE OF THE PUZZLE. 4726 03:16:49,560 --> 03:16:53,160 WHAT WE REALLY WOULD LIKE TO 4727 03:16:53,160 --> 03:16:55,480 KNOW IS HOW THE DIFFERENTIATE 4728 03:16:55,480 --> 03:16:57,360 WHAT NORMAL PROCESS OF 4729 03:16:57,360 --> 03:16:58,440 ADAPTATION TO INJURY, 4730 03:16:58,440 --> 03:17:00,960 INFLAMMATION, TO AGING, AS WELL 4731 03:17:00,960 --> 03:17:09,360 AS OTHER FACTORS ARE COUNTER 4732 03:17:09,360 --> 03:17:12,760 BALANCED BY PLASTICITY, AT WHAT 4733 03:17:12,760 --> 03:17:13,880 POINT DOES EQUILIBRIUM BECOME 4734 03:17:13,880 --> 03:17:19,000 UNSTABLE, WE WOULD LIKE TO TRY 4735 03:17:19,000 --> 03:17:20,640 TO UNDERSTAND TRANSITION TO 4736 03:17:20,640 --> 03:17:23,280 CHRONIC PAIN. 4737 03:17:23,280 --> 03:17:24,720 INDIVIDUAL BIOMARKERS ARE ONLY 4738 03:17:24,720 --> 03:17:26,360 GIVING US A SNAPSHOT OF THIS 4739 03:17:26,360 --> 03:17:27,120 COMPLEX PROBLEM. 4740 03:17:27,120 --> 03:17:33,280 SO WHAT WE REALLY NEED IS MODELS 4741 03:17:33,280 --> 03:17:34,560 TO INTERPRET MULTIMODAL 4742 03:17:34,560 --> 03:17:35,080 BIOMARKERS. 4743 03:17:35,080 --> 03:17:39,400 I LOOK FOR WASHED TO THE -- 4744 03:17:39,400 --> 03:17:40,160 FORWARD TO THE DISCUSSION. 4745 03:17:40,160 --> 03:17:41,240 >>THANK YOU. 4746 03:17:41,240 --> 03:17:49,520 NOW WE MOVE INTO THE PANEL 4747 03:17:49,520 --> 03:17:50,840 DISCUSSION SEGMENT. 4748 03:17:50,840 --> 03:17:53,520 FIRST, SCOTT? 4749 03:17:53,520 --> 03:17:58,360 4750 03:17:58,360 --> 03:18:00,360 >>FOUR YEARS INTO THIS WHEN ARE 4751 03:18:00,360 --> 03:18:05,240 WE GOING TO LEARN TO UNMUTE? 4752 03:18:05,240 --> 03:18:08,560 I WANT TO COMPLIMENT THE 4753 03:18:08,560 --> 03:18:09,440 SPEAKERS. 4754 03:18:09,440 --> 03:18:10,640 FABULOUS TECHNOLOGIES. 4755 03:18:10,640 --> 03:18:12,720 AND REALLY EXCITING PROSPECTS. 4756 03:18:12,720 --> 03:18:16,760 I WANTED TO SHARE A LITTLE 4757 03:18:16,760 --> 03:18:20,680 PERSPECTIVE AND KIND OF ASK THE 4758 03:18:20,680 --> 03:18:21,480 SPEAKERS FOR THEIR PERSPECTIVES. 4759 03:18:21,480 --> 03:18:26,400 IT WAS IN THE LATE '80s THAT I 4760 03:18:26,400 --> 03:18:29,160 REPORTED A METHOD TO MEASURE 4761 03:18:29,160 --> 03:18:36,920 KNEE REPLACEMENT MOTION IN THREE 4762 03:18:36,920 --> 03:18:38,760 DIMENSIONS, A LOT OF EXCITEMENT 4763 03:18:38,760 --> 03:18:40,960 WITH SURGEONS, SCOTT, THAT'S 4764 03:18:40,960 --> 03:18:45,840 GREAT, BUT THERE'S ALWAYS A 4765 03:18:45,840 --> 03:18:46,240 "BUT." 4766 03:18:46,240 --> 03:18:47,960 YOU REPORTED ON STAIR CLIMBING, 4767 03:18:47,960 --> 03:18:51,240 MY PATIENTS ALSO WALK OR TRY TO 4768 03:18:51,240 --> 03:18:53,680 HAVE DEEP FLEXION. 4769 03:18:53,680 --> 03:18:55,280 OR THERE WAS -- I'M TREATING THE 4770 03:18:55,280 --> 03:18:57,520 KNEE BUT I THINK THE PROBLEM IS 4771 03:18:57,520 --> 03:18:59,800 FOOT, ANKLE, HIP, LOW BACK. 4772 03:18:59,800 --> 03:19:05,360 AND SO ONE QUESTION FOR THE 4773 03:19:05,360 --> 03:19:06,240 SPEAKERS IS CONTEXTUALIZING 4774 03:19:06,240 --> 03:19:08,760 THEIR REGION OF INTEREST WHERE 4775 03:19:08,760 --> 03:19:10,000 THEY ARE MAKING MEASUREMENTS 4776 03:19:10,000 --> 03:19:17,120 EITHER FOR A GAMUT OF DYNAMIC 4777 03:19:17,120 --> 03:19:18,320 OBSERVATIONAL OPPORTUNITIES OR 4778 03:19:18,320 --> 03:19:23,040 INTEGRATING IT INTO SORT OF THE 4779 03:19:23,040 --> 03:19:24,240 WHOLE PERSON AND SYMPTOM 4780 03:19:24,240 --> 03:19:25,040 SOMETHING. 4781 03:19:25,040 --> 03:19:29,320 THE OTHER THINK, FEEDBACK FROM 4782 03:19:29,320 --> 03:19:30,720 SURGEONS, IS THAT'S GREAT, VERY 4783 03:19:30,720 --> 03:19:31,800 INTERESTING STUDY. 4784 03:19:31,800 --> 03:19:34,120 I DON'T REALLY DO THAT. 4785 03:19:34,120 --> 03:19:38,360 HOW CAN I USE THIS METHOD ON MY 4786 03:19:38,360 --> 03:19:41,200 PATIENTS? 4787 03:19:41,200 --> 03:19:44,200 SO IF THE PANELISTS WOULD BE 4788 03:19:44,200 --> 03:19:47,360 WILLING TO MAYBE COMMENT ON THE 4789 03:19:47,360 --> 03:19:52,840 PATHWAY OR TRAJECTORY, MAYBE NIH 4790 03:19:52,840 --> 03:19:57,240 FUNDING THEY NEED A VERY 4791 03:19:57,240 --> 03:19:59,000 PROMISING IMAGE AND ANALYSIS 4792 03:19:59,000 --> 03:20:04,680 METHOD TO SOMETHING CLINICALLY 4793 03:20:04,680 --> 03:20:05,280 IMPLEMENTABLE AND PRACTICAL. 4794 03:20:05,280 --> 03:20:11,920 THANK YOU. 4795 03:20:11,920 --> 03:20:13,400 >>I CAN COMMENT. 4796 03:20:13,400 --> 03:20:19,240 I HAVE THOUGHT ABOUT THIS A LOT 4797 03:20:19,240 --> 03:20:20,880 WITH OUR DYNAMIC WRIST PROGRAM. 4798 03:20:20,880 --> 03:20:23,200 ESPECIALLY IN A PAST LIFE, I WAS 4799 03:20:23,200 --> 03:20:28,560 ONCE IN THE DEVICE INDUSTRY. 4800 03:20:28,560 --> 03:20:29,920 I THINK HOW THINGS WILL ACTUALLY 4801 03:20:29,920 --> 03:20:30,880 GET OUT THERE. 4802 03:20:30,880 --> 03:20:31,440 IT'S A BIG CHALLENGE. 4803 03:20:31,440 --> 03:20:33,560 I DON'T KNOW IF I HAVE THE RIGHT 4804 03:20:33,560 --> 03:20:35,480 ANSWER FOR WHAT THE NEXT SORT OF 4805 03:20:35,480 --> 03:20:38,080 NIH FUNDING IS TO TAKE IT THERE 4806 03:20:38,080 --> 03:20:39,840 BECAUSE A LOT OF THE THINGS YOU 4807 03:20:39,840 --> 03:20:41,200 NEED TO DO TO TRANSLATE IT AND 4808 03:20:41,200 --> 03:20:42,720 GET IT TO THE POINT WHERE IT 4809 03:20:42,720 --> 03:20:44,440 COULD BE USED WIDELY IN THE 4810 03:20:44,440 --> 03:20:47,840 CLINIC ARE NOT THINGS THAT SELL 4811 03:20:47,840 --> 03:20:49,800 WELL IN AN R01 PROPOSAL. 4812 03:20:49,800 --> 03:20:52,400 AND SO ONE KEY IS I THINK YOU 4813 03:20:52,400 --> 03:20:56,360 HAVE TO HAVE AN INDUSTRY TARGET, 4814 03:20:56,360 --> 03:20:57,840 SOMEBODY TO PARTNER WITH, 4815 03:20:57,840 --> 03:21:02,640 WHETHER IT'S A BIG VENDOR OR 4816 03:21:02,640 --> 03:21:03,400 SMALL BUSINESS, WITH A SMALL 4817 03:21:03,400 --> 03:21:05,680 BUSINESS YOU CAN GO INTO THE 4818 03:21:05,680 --> 03:21:07,520 SMALL BUSINESS FUNDING 4819 03:21:07,520 --> 03:21:08,280 OPPORTUNITIES AND THINGS. 4820 03:21:08,280 --> 03:21:09,720 THAT'S PART OF IT. 4821 03:21:09,720 --> 03:21:13,760 THAT'S REALLY NUTS AND BOLTS 4822 03:21:13,760 --> 03:21:15,320 LOGISTICS ISSUES. 4823 03:21:15,320 --> 03:21:17,560 FROM A MORE TECHNICAL 4824 03:21:17,560 --> 03:21:20,360 STANDPOINT, ONE OF THE THINGS 4825 03:21:20,360 --> 03:21:23,200 I'VE NOTICED IS FOCUSING, LIKE 4826 03:21:23,200 --> 03:21:24,480 YOU SAID, FOCUSING ON SPECIFIC 4827 03:21:24,480 --> 03:21:27,200 QUESTIONS AND TARGETS THAT ARE 4828 03:21:27,200 --> 03:21:28,880 HOPEFULLY BROADLY APPLICABLE IN 4829 03:21:28,880 --> 03:21:30,400 THE WRIST CASE, THE REASON I 4830 03:21:30,400 --> 03:21:31,400 ACTUALLY GOT INTO THIS, THIS WAS 4831 03:21:31,400 --> 03:21:33,840 A WEIRD THING FOR ME TO GET INTO 4832 03:21:33,840 --> 03:21:35,360 SEVERAL YEARS AGO. 4833 03:21:35,360 --> 03:21:37,400 I JUST HAD, YOU KNOW, A SURGEON 4834 03:21:37,400 --> 03:21:40,480 AND RADIOLOGIST ASK ME IF WE 4835 03:21:40,480 --> 03:21:42,320 COULD DO DYNAMIC IMAGING OF THE 4836 03:21:42,320 --> 03:21:43,880 WRIST BECAUSE THEY HAVE ALWAYS 4837 03:21:43,880 --> 03:21:47,480 STRUGGLED TO UNDERSTAND THE ROLE 4838 03:21:47,480 --> 03:21:50,360 OF THE INTRINSIC AND EXTRINSIC 4839 03:21:50,360 --> 03:21:50,960 CARPAL LIGAMENTS MANAGING 4840 03:21:50,960 --> 03:21:51,920 INSTABILITY. 4841 03:21:51,920 --> 03:21:52,760 THAT'S BEEN THE GUIDING FOCUS OF 4842 03:21:52,760 --> 03:21:55,920 THE ENTIRE PROGRAM. 4843 03:21:55,920 --> 03:21:59,200 IT'S A VERY TARGETED QUESTION. 4844 03:21:59,200 --> 03:22:00,280 IT'S CARPAL INSTABILITY, AND 4845 03:22:00,280 --> 03:22:02,160 IT'S THE ROLE OF THESE 4846 03:22:02,160 --> 03:22:03,560 LIGAMENTS, AND THE SURGEONS HAVE 4847 03:22:03,560 --> 03:22:05,200 VERY SPECIFIC TARGETS ON IT. 4848 03:22:05,200 --> 03:22:10,600 I MEAN, THEY GO IN WITH SPECIFIC 4849 03:22:10,600 --> 03:22:11,800 APPROACHES, AND KNOWING WHICH 4850 03:22:11,800 --> 03:22:13,880 LIGAMENTS ARE GOING TO BE 4851 03:22:13,880 --> 03:22:15,480 IMPACTED AND MAYBE SOMEDAY 4852 03:22:15,480 --> 03:22:18,040 HAVING SOME GUIDANCE ON HOW THEY 4853 03:22:18,040 --> 03:22:20,240 MIGHT BE ABLE TO STRATEGICALLY 4854 03:22:20,240 --> 03:22:21,760 PERFORM THOSE REPAIRS, OR WHEN 4855 03:22:21,760 --> 03:22:23,520 TO PERFORM REPAIRS. 4856 03:22:23,520 --> 03:22:24,760 IT'S A VERY FOCUSED QUESTION 4857 03:22:24,760 --> 03:22:26,160 BECAUSE I AGREE WITH YOUR 4858 03:22:26,160 --> 03:22:26,720 CONCERN. 4859 03:22:26,720 --> 03:22:29,440 IF IT'S TOO BROAD AND NOT 4860 03:22:29,440 --> 03:22:30,400 CLEARLY APPLICABLE, THE UPTAKE 4861 03:22:30,400 --> 03:22:31,600 IS GOING TO BE TOUGH. 4862 03:22:31,600 --> 03:22:34,400 EVEN IF YOU ARE ABLE TO 4863 03:22:34,400 --> 03:22:36,640 COMMERCIALIZE IT. 4864 03:22:36,640 --> 03:22:38,000 NOBODY'S USES IT, RIGHT? 4865 03:22:38,000 --> 03:22:40,720 SO THOSE ARE MY TWO CENTS ON IT. 4866 03:22:40,720 --> 03:22:43,680 >>LET ME TRY TO ADD SOMETHING 4867 03:22:43,680 --> 03:22:47,600 ON THE CLINICAL TRANSLATION 4868 03:22:47,600 --> 03:22:49,080 SIDE. 4869 03:22:49,080 --> 03:22:51,360 I FIGURE THAT TECHNICAL 4870 03:22:51,360 --> 03:22:53,560 INVESTIGATORS THAT WORKS A LOT 4871 03:22:53,560 --> 03:22:57,600 ON MAKING IMAGING FASTER, MAKING 4872 03:22:57,600 --> 03:23:00,920 THE PROCESS AUTOMATIC, AND OFTEN 4873 03:23:00,920 --> 03:23:03,080 WE START, WHEN ONE DESCRIBED, 4874 03:23:03,080 --> 03:23:05,080 YOU KNOW, BULLET POINTS ON WHY 4875 03:23:05,080 --> 03:23:07,680 THIS TECHNIQUE IS NOT CLINICAL 4876 03:23:07,680 --> 03:23:10,080 TRANSLATABLE, SORE NOT 4877 03:23:10,080 --> 03:23:12,200 CLINICALLY TRANSLATED YET OFTEN 4878 03:23:12,200 --> 03:23:14,880 STARTS WITH TECHNICAL OBSTACLES. 4879 03:23:14,880 --> 03:23:18,400 WE FOCUS ON SOLVING TECHNICAL 4880 03:23:18,400 --> 03:23:19,840 OBSTACLE FORCE, AND OFT WEAN 4881 03:23:19,840 --> 03:23:22,160 FORGET TO IMAGINE THE SCENARIO, 4882 03:23:22,160 --> 03:23:23,240 OKAY, LET'S IMAGINE SCENARIO IN 4883 03:23:23,240 --> 03:23:25,960 WHICH ALL OF THESE ARE SOLVED, 4884 03:23:25,960 --> 03:23:28,360 WHAT WILL BE THE -- IS THIS 4885 03:23:28,360 --> 03:23:29,280 ACTIONABLE FOR REAL? 4886 03:23:29,280 --> 03:23:32,640 EVEN IF IT WILL BE A SECOND 4887 03:23:32,640 --> 03:23:34,960 ACQUISITION, EVEN IF THE PROCESS 4888 03:23:34,960 --> 03:23:39,400 WILL BE COMPLETELY AUTOMATIC, SO 4889 03:23:39,400 --> 03:23:40,360 WHAT? 4890 03:23:40,360 --> 03:23:41,880 WHAT ARE RADIOLOGISTS OR 4891 03:23:41,880 --> 03:23:43,640 ORTHOPEDIC SURGEON WILL CHANGE 4892 03:23:43,640 --> 03:23:45,080 THE CLINICAL MANAGEMENT, NOW 4893 03:23:45,080 --> 03:23:46,200 THAT HE HAS THIS ADDITIONAL 4894 03:23:46,200 --> 03:23:50,480 INFORMATION ON THE PLATE? 4895 03:23:50,480 --> 03:23:53,400 AND OFTEN THE DISCUSSION COMES 4896 03:23:53,400 --> 03:23:56,800 EITHER AFTER OR IS NOT THE FIRST 4897 03:23:56,800 --> 03:23:59,640 QUESTION TO ASK, AS, OKAY, THE 4898 03:23:59,640 --> 03:24:01,920 PROBLEM, WHY MRI IS NOT 4899 03:24:01,920 --> 03:24:04,680 TRANSLATED, BECAUSE IT'S SLOW, 4900 03:24:04,680 --> 03:24:06,640 BECAUSE THE PROCESS IS LONG, AND 4901 03:24:06,640 --> 03:24:09,560 I'M NOT SURE THE PROBLEM IS 4902 03:24:09,560 --> 03:24:10,280 THERE. 4903 03:24:10,280 --> 03:24:13,960 WE KNOW OR WE CAN SOLVE THAT, 4904 03:24:13,960 --> 03:24:17,360 BUT MAKING IT ACTIONABLE IS 4905 03:24:17,360 --> 03:24:21,440 WHERE THE REAL PROBLEM IS. 4906 03:24:21,440 --> 03:24:25,040 AND I THINK THERE IS A VERY 4907 03:24:25,040 --> 03:24:26,880 IMPORTANT APPLICATION IN 4908 03:24:26,880 --> 03:24:28,840 RESEARCH WHICH STILL MAKES 4909 03:24:28,840 --> 03:24:34,320 INCREDIBLY VALUABLE, SO THE 4910 03:24:34,320 --> 03:24:36,960 ABILITY OF PREDICTING WITH 4911 03:24:36,960 --> 03:24:37,600 CERTAIN PROBABILITY, INCIDENCE 4912 03:24:37,600 --> 03:24:41,640 OF OSTEOARTHRITIS IN A SUBJECT 4913 03:24:41,640 --> 03:24:42,400 WITH KNOW RADIOGRAPHIC EVIDENCE 4914 03:24:42,400 --> 03:24:52,840 COULD BE GAME CHANGING 4915 03:24:55,640 --> 03:24:56,200 INCLUSION 4916 03:24:56,200 --> 03:24:57,800 IN CLINICAL TRIALS, RELIABLE 4917 03:24:57,800 --> 03:25:00,280 DATA, INCLUSION CRITERIA FOR A 4918 03:25:00,280 --> 03:25:00,800 LARGE EPIDEMIOLOGY STUDY 4919 03:25:00,800 --> 03:25:03,920 PROBABLY WILL BE ABLE TO OBSERVE 4920 03:25:03,920 --> 03:25:05,000 THE PATHOGENESIS OF THE DISEASE 4921 03:25:05,000 --> 03:25:06,880 BETTER BECAUSE WE CAN ACTUALLY 4922 03:25:06,880 --> 03:25:10,040 PREDICT WHO IS GOING TO 4923 03:25:10,040 --> 03:25:10,320 PROGRESS. 4924 03:25:10,320 --> 03:25:14,360 YEAH, SO PROBABLY THOSE ARE MY 4925 03:25:14,360 --> 03:25:16,400 TWO POINTS ON THE TRANSLATION. 4926 03:25:16,400 --> 03:25:24,240 >>IF I CAN ADD, I AGREE WITH 4927 03:25:24,240 --> 03:25:25,360 VALLENTINA, TO ACT ON THE 4928 03:25:25,360 --> 03:25:27,240 INFORMATION IS IMPORTANT BUT FOR 4929 03:25:27,240 --> 03:25:28,640 THAT NOT ONLY WE NEED 4930 03:25:28,640 --> 03:25:30,640 PARTNERSHIP WITH INDUSTRY, WE 4931 03:25:30,640 --> 03:25:32,560 NEED PARTNERSHIP WITH SURGEONS 4932 03:25:32,560 --> 03:25:34,800 BECAUSE OFTEN THE MAIN ISSUES 4933 03:25:34,800 --> 03:25:36,320 THAT SURGEONS ARE NOT VERY 4934 03:25:36,320 --> 03:25:39,040 WILLING TO COLLABORATE, DON'T 4935 03:25:39,040 --> 03:25:39,920 KNOW WHAT THEY NEED. 4936 03:25:39,920 --> 03:25:43,520 BUT IT'S HARD TO UNDERSTAND 4937 03:25:43,520 --> 03:25:44,840 THEIR NEEDS AND MAYBE WE SHOULD 4938 03:25:44,840 --> 03:25:46,880 DO IT ALL THE WAY AROUND, WE 4939 03:25:46,880 --> 03:25:50,640 TELL THEM WHAT TO DO BY USING 4940 03:25:50,640 --> 03:25:54,000 OUR FINDINGS, AND ALSO I MEAN A 4941 03:25:54,000 --> 03:25:59,200 LOT OF THE CORRELATION WITH 4942 03:25:59,200 --> 03:26:03,680 CLINICAL MRI, OFTEN BASED THAT 4943 03:26:03,680 --> 03:26:05,680 GROUND TRUTH IS GROUND TRUTH, 4944 03:26:05,680 --> 03:26:08,800 BUT SOMETIMES IT'S NOT A GROUND 4945 03:26:08,800 --> 03:26:10,560 TRUTH, OFTEN IF IT'S NOT 4946 03:26:10,560 --> 03:26:12,800 SOMETHING THAT'S GOING TO 4947 03:26:12,800 --> 03:26:17,360 CHANGE, PAY A LOT OF ATTENTION 4948 03:26:17,360 --> 03:26:19,320 IN DOING THIS ANNOTATION, ALL OF 4949 03:26:19,320 --> 03:26:21,360 THE SAME, IMPOSSIBLE FOR TEN 4950 03:26:21,360 --> 03:26:25,040 PATIENTS, SO I THINK IF THEY 4951 03:26:25,040 --> 03:26:27,320 REALLY WANT US TO DEVELOP 4952 03:26:27,320 --> 03:26:28,400 SOMETHING THAT'S NEEDED 4953 03:26:28,400 --> 03:26:29,560 TRANSLATED CLINICALLY, THEY NEED 4954 03:26:29,560 --> 03:26:32,120 TO BE PARTNER TO BE INVOLVED IN 4955 03:26:32,120 --> 03:26:34,920 KIND OF GRANT SUBMISSION AND 4956 03:26:34,920 --> 03:26:36,760 INVOLVED IN THE WORK. 4957 03:26:36,760 --> 03:26:39,080 >>I CAN FOLLOW UP A LITTLE BIT 4958 03:26:39,080 --> 03:26:46,600 ON ALSO SORT OF WHAT VALENTINA 4959 03:26:46,600 --> 03:26:48,480 TALKED ABOUT, AS WE HEARD TODAY 4960 03:26:48,480 --> 03:26:49,560 SCANS ARE BECOMING SO MUCH MORE 4961 03:26:49,560 --> 03:26:52,400 EFFICIENT IN TERMS OF NOT ONLY 4962 03:26:52,400 --> 03:26:53,960 SORT OF HOW FAST THEY ARE BEING 4963 03:26:53,960 --> 03:26:55,720 RUN BUT AMOUNT OF DATA THAT'S 4964 03:26:55,720 --> 03:26:56,800 BEING COLLECTED. 4965 03:26:56,800 --> 03:27:01,200 YOU CAN DO A SINGLE SCAN AND GET 4966 03:27:01,200 --> 03:27:02,600 MULTIPLE MAPS, VOLUME RENDERING, 4967 03:27:02,600 --> 03:27:05,400 BONE SHAPE, SO THIS IS GREAT FOR 4968 03:27:05,400 --> 03:27:07,160 DATA STANDPOINT OF STUDYING 4969 03:27:07,160 --> 03:27:07,520 DISEASE. 4970 03:27:07,520 --> 03:27:09,440 IT'S NOT NECESSARILY GREAT FROM 4971 03:27:09,440 --> 03:27:11,440 LIKE AN OVERLOADING THE 4972 03:27:11,440 --> 03:27:12,000 CLINICIAN STANDPOINT. 4973 03:27:12,000 --> 03:27:14,160 SO I THINK THERE NEEDS TO BE 4974 03:27:14,160 --> 03:27:16,040 MORE DONE ON ANALYSIS FRONT TO 4975 03:27:16,040 --> 03:27:17,560 SORT OF SAY THIS IS THE MEASURE 4976 03:27:17,560 --> 03:27:21,360 THAT YOU SHOULD BE USING, AND 4977 03:27:21,360 --> 03:27:23,040 PARTICULARLY CARRYING TO THE 4978 03:27:23,040 --> 03:27:23,360 APPLICATION. 4979 03:27:23,360 --> 03:27:27,520 I WILL SAY THAT PARTICULARLY FOR 4980 03:27:27,520 --> 03:27:28,000 QUANTITATIVE IMAGING THE 4981 03:27:28,000 --> 03:27:29,360 CLINICAL ROLE MAY NOT BE THERE 4982 03:27:29,360 --> 03:27:31,600 YET, BUT I THINK THERE WILL BE A 4983 03:27:31,600 --> 03:27:34,520 TIME WHEN THERE WILL BE A ROLE 4984 03:27:34,520 --> 03:27:35,920 FOR QUANTITATIVE IMAGING, AND 4985 03:27:35,920 --> 03:27:38,240 FOR ME THAT I THINK WILL COME 4986 03:27:38,240 --> 03:27:40,880 WHEN THERE ARE TREATMENTS. 4987 03:27:40,880 --> 03:27:42,760 PARTICULARLY FOR D MODES, THEY 4988 03:27:42,760 --> 03:27:45,160 ARE ALL TARGETING CARTILAGE, 4989 03:27:45,160 --> 03:27:46,600 BONE REMODEELING, INFLAMMATION, 4990 03:27:46,600 --> 03:27:48,080 BEING ABLE TO SELECT WHICH 4991 03:27:48,080 --> 03:27:49,320 PATIENTS ARE GOING TO BENEFIT 4992 03:27:49,320 --> 03:27:53,040 FROM DRUGS I THINK WILL BE A BIG 4993 03:27:53,040 --> 03:27:55,520 ROLE NOT ONLY IN HELPING THE 4994 03:27:55,520 --> 03:27:57,720 SORT OF TRIALS BUT ALSO ONCE 4995 03:27:57,720 --> 03:27:59,360 THEY GET INTO THE CLINICS TO BE 4996 03:27:59,360 --> 03:28:00,760 ABLE TO SAY LIKE THIS PERSON 4997 03:28:00,760 --> 03:28:02,760 WILL BENEFIT FROM THIS, AND 4998 03:28:02,760 --> 03:28:04,760 MONITORING SHORTLY AFTER SO THEY 4999 03:28:04,760 --> 03:28:06,960 ARE NOT ON A VERY EXPENSIVE 5000 03:28:06,960 --> 03:28:08,800 BIOLOGIC FOR SUPER LONG. 5001 03:28:08,800 --> 03:28:10,120 THE SYSTEMS QUESTION, I THINK 5002 03:28:10,120 --> 03:28:11,880 THAT ONE IS REALLY HARD, BECAUSE 5003 03:28:11,880 --> 03:28:16,160 I THINK A LOT OF THESE THINGS 5004 03:28:16,160 --> 03:28:16,880 ARE SYSTEMS-TYPE, YOU KNOW, 5005 03:28:16,880 --> 03:28:19,320 REASONS WHY YOU MIGHT BE HAVING 5006 03:28:19,320 --> 03:28:19,560 PAIN. 5007 03:28:19,560 --> 03:28:22,080 BUT YOU COME IN WITH KNEE PAIN 5008 03:28:22,080 --> 03:28:26,440 AND THE IDEA OF DOING LIKE A 5009 03:28:26,440 --> 03:28:27,200 WHOLE LOWER LIMB SCAN, YOU KNOW, 5010 03:28:27,200 --> 03:28:28,720 I THINK WE'RE REALLY FAR AWAY 5011 03:28:28,720 --> 03:28:30,040 FROM THAT. 5012 03:28:30,040 --> 03:28:31,160 SO, AGAIN, I THINK THAT WOULD BE 5013 03:28:31,160 --> 03:28:33,000 INTERESTING TO PUT MORE EMPHASIS 5014 03:28:33,000 --> 03:28:34,520 ON THAT FROM A RESEARCH 5015 03:28:34,520 --> 03:28:35,960 STANDPOINT BECAUSE I DON'T THINK 5016 03:28:35,960 --> 03:28:39,400 WE'RE THERE YET ON RESEARCH 5017 03:28:39,400 --> 03:28:40,640 BASIS BUT CLINICALLY, AGAIN, THE 5018 03:28:40,640 --> 03:28:42,000 ONLY THING I'VE SEEN IS LIKE 5019 03:28:42,000 --> 03:28:44,720 MAYBE BACK PAIN LOOKING FOR 5020 03:28:44,720 --> 03:28:46,360 NEUROPATHIC PAIN SOURCES. 5021 03:28:46,360 --> 03:28:49,320 BUT IT'S VERY LIMITED. 5022 03:28:49,320 --> 03:28:54,560 5023 03:28:54,560 --> 03:28:55,800 >>THANK YOU. 5024 03:28:55,800 --> 03:29:00,720 THERE'S ANOTHER QUESTION FOR THE 5025 03:29:00,720 --> 03:29:02,480 PANELISTS, RELATED TO WHAT WHAT 5026 03:29:02,480 --> 03:29:04,520 JUST MENTIONED. 5027 03:29:04,520 --> 03:29:06,160 IN LIGHT OF BIOLOGICAL AND 5028 03:29:06,160 --> 03:29:08,240 MOLECULAR MECHANISMS THAT HAVE 5029 03:29:08,240 --> 03:29:11,000 BEEN DISCUSSED OVER THE TWO 5030 03:29:11,000 --> 03:29:13,000 DAYS, CAN YOU DESCRIBE 5031 03:29:13,000 --> 03:29:14,600 PRIORITIES IN TERMS OF 5032 03:29:14,600 --> 03:29:19,640 ADDITIONAL DATA OR METHOD THAT 5033 03:29:19,640 --> 03:29:20,400 COULD ENHANCE PREDICTIVE 5034 03:29:20,400 --> 03:29:24,920 VALIDITY OR AC ACCURACY OF YOUR 5035 03:29:24,920 --> 03:29:26,480 APPROACH AND IDEAL COMPOSITE TO 5036 03:29:26,480 --> 03:29:27,880 PREDICT PATIENT PAIN OR 5037 03:29:27,880 --> 03:29:30,160 FUNCTION? 5038 03:29:30,160 --> 03:29:32,720 5039 03:29:32,720 --> 03:29:34,960 >>MAYBE I CAN WEIGH IN. 5040 03:29:34,960 --> 03:29:38,280 SO, I THINK WE HEARD FROM REALLY 5041 03:29:38,280 --> 03:29:40,920 EXCELLENT TALKS ON DIFFERENT 5042 03:29:40,920 --> 03:29:43,320 BIOMARKERS AND DIFFERENT REALLY 5043 03:29:43,320 --> 03:29:44,520 AMAZING IMAGING METHODS. 5044 03:29:44,520 --> 03:29:46,000 ALSO LOOKING AT MULTIPLE 5045 03:29:46,000 --> 03:29:48,800 DIFFERENT TYPES OF TISSUES. 5046 03:29:48,800 --> 03:29:51,240 I THINK THAT CRITICAL THING 5047 03:29:51,240 --> 03:29:53,160 WE'RE LACKING IS ABILITY TO 5048 03:29:53,160 --> 03:29:55,240 STUDY THESE THINGS OVER TIME, 5049 03:29:55,240 --> 03:29:59,200 AND UNDERSTAND WHAT IS A NATURAL 5050 03:29:59,200 --> 03:30:00,080 PROGRESSION AND NATURAL 5051 03:30:00,080 --> 03:30:02,760 ADAPTATION VERSUS WHAT IS 5052 03:30:02,760 --> 03:30:04,560 ABNORMAL ADAPTATION. 5053 03:30:04,560 --> 03:30:08,160 SO THAT, TO ME, IS A VERY TRICKY 5054 03:30:08,160 --> 03:30:10,840 CHALLENGE BECAUSE OBVIOUSLY 5055 03:30:10,840 --> 03:30:12,760 BEING ABLE TO DO SERIAL IMAGING 5056 03:30:12,760 --> 03:30:16,040 SCANS ON THE SAME PERSON OVER A 5057 03:30:16,040 --> 03:30:21,400 LONG PERIOD OF TIME IS 5058 03:30:21,400 --> 03:30:23,000 LOGISTICALLY CHALLENGING AND 5059 03:30:23,000 --> 03:30:24,440 CLINICALLY NEARLY IMPOSSIBLE, 5060 03:30:24,440 --> 03:30:24,840 PERHAPS. 5061 03:30:24,840 --> 03:30:27,640 SO THE QUESTION IS HOW CAN WE 5062 03:30:27,640 --> 03:30:29,240 FIGURE OUT WHAT IS A MINIMAL SET 5063 03:30:29,240 --> 03:30:32,120 OF DATA WE CAN TRACK OVER TIME 5064 03:30:32,120 --> 03:30:34,680 TO REALLY UNDERSTAND THE SORT OF 5065 03:30:34,680 --> 03:30:37,320 TRAJECTORY OF THE PAIN SYNDROME, 5066 03:30:37,320 --> 03:30:42,640 AND TRY TO UNDERSTAND WHAT IS AN 5067 03:30:42,640 --> 03:30:43,160 ABNORMAL ADAPTATION. 5068 03:30:43,160 --> 03:30:45,600 >>AND CONNECTING WHAT YOU'RE 5069 03:30:45,600 --> 03:30:52,760 SAYING WITH WHAT FELIKS WAS 5070 03:30:52,760 --> 03:30:53,600 SAYING, ANSWERING THE MINIMUM 5071 03:30:53,600 --> 03:30:55,600 VALUABLE SET OF DATA WE SHOULD 5072 03:30:55,600 --> 03:30:57,120 COLLECT ON A PATIENT, I THINK 5073 03:30:57,120 --> 03:30:59,800 THE PROBLEM IS MORE ON HAVING 5074 03:30:59,800 --> 03:31:03,040 SOMETHING THAT IS ABLE TO 5075 03:31:03,040 --> 03:31:04,480 PHENOTYPE THE PATIENT FIRST, AND 5076 03:31:04,480 --> 03:31:07,600 THEN TRIAGE THE MINIMUM SET OF 5077 03:31:07,600 --> 03:31:11,080 DATA BECAUSE FOR A CERTAIN 5078 03:31:11,080 --> 03:31:12,240 PATIENT, THOSE DATA MIGHT BE 5079 03:31:12,240 --> 03:31:16,200 RELATED TO THE SHAPE OF THE BONE 5080 03:31:16,200 --> 03:31:18,080 AND FOR THAT PATIENT YOU MIGHT 5081 03:31:18,080 --> 03:31:19,600 WANT TO INVEST IN A PET SCAN AS 5082 03:31:19,600 --> 03:31:22,360 WELL BECAUSE IT'S REALLY ABOUT 5083 03:31:22,360 --> 03:31:23,800 INFLAMMATION, AND IT'S REALLY 5084 03:31:23,800 --> 03:31:25,560 ABOUT BONE REMODELING FOR HIM OR 5085 03:31:25,560 --> 03:31:26,640 FOR HER. 5086 03:31:26,640 --> 03:31:32,360 AND FOR ANOTHER PATIENT IT'S ALL 5087 03:31:32,360 --> 03:31:33,120 CARTILAGE. 5088 03:31:33,120 --> 03:31:36,680 AND HAVING FIRST TRIAGING AND 5089 03:31:36,680 --> 03:31:38,960 PHENOTYPING, IT'S PROBABLY WHAT 5090 03:31:38,960 --> 03:31:41,560 WE ARE LACKING AND BEING ABLE TO 5091 03:31:41,560 --> 03:31:43,280 PHENOTYPE CORRECTLY THE PATIENT 5092 03:31:43,280 --> 03:31:48,160 WILL SOLVE A LOT OF THE OTHER 5093 03:31:48,160 --> 03:31:49,480 PROBLEM IN OVERLOADING OF 5094 03:31:49,480 --> 03:31:54,360 INFORMATION, DECIDING WHAT IS 5095 03:31:54,360 --> 03:31:59,000 BEST, MAKING SCANNER SHORTER, 5096 03:31:59,000 --> 03:32:01,720 BUT PERSONALIZE THE DATA 5097 03:32:01,720 --> 03:32:03,320 COLLECTION IS PROBABLY WHAT CAN 5098 03:32:03,320 --> 03:32:09,720 SOLVE A LOT OF THE DOWNSTREAM 5099 03:32:09,720 --> 03:32:11,120 PROBLEM THAT WE'RE DESCRIBING. 5100 03:32:11,120 --> 03:32:12,560 >>COLLAGEN SCANNING, RIGHT? 5101 03:32:12,560 --> 03:32:16,160 YOU SCAN AND DO MORE SCANS AS 5102 03:32:16,160 --> 03:32:17,760 YOU LEARN BETTER METHODS. 5103 03:32:17,760 --> 03:32:19,920 >>IF I CAN FOLLOW UP, ONE MORE 5104 03:32:19,920 --> 03:32:21,400 POINT TO THAT, SO I THINK WHEN 5105 03:32:21,400 --> 03:32:23,280 WE TALK ABOUT CHRONIC PAIN 5106 03:32:23,280 --> 03:32:24,160 OBVIOUSLY CENTRAL SENSITIZATION 5107 03:32:24,160 --> 03:32:27,960 IS ONE OF THE KEY DRIVING -- 5108 03:32:27,960 --> 03:32:29,320 UNDERLYING MECHANISMS. 5109 03:32:29,320 --> 03:32:32,240 IT IS VERY DIFFICULT TO 5110 03:32:32,240 --> 03:32:35,000 SOMETIMES DISASSOCIATE WHAT IS 5111 03:32:35,000 --> 03:32:39,040 THE PRIMARY DRIVER FOR CENTRAL 5112 03:32:39,040 --> 03:32:40,360 SENSITIZATION VERSUS SECONDARY 5113 03:32:40,360 --> 03:32:41,120 DOWNSTREAM EFFECT. 5114 03:32:41,120 --> 03:32:46,280 AND THIS IS, AGAIN, SOMETHING 5115 03:32:46,280 --> 03:32:49,080 THAT NEEDS TO BE INVESTIGATED A 5116 03:32:49,080 --> 03:32:51,960 LITTLE BIT MORE TO UNDERSTAND 5117 03:32:51,960 --> 03:32:52,640 WE'RE FINDING DIFFERENCES 5118 03:32:52,640 --> 03:32:55,280 BETWEEN PAIN GROUP AND NON-PAIN 5119 03:32:55,280 --> 03:32:55,480 GROUP. 5120 03:32:55,480 --> 03:32:59,800 BUT WHAT EXACTLY IS PRIMARY 5121 03:32:59,800 --> 03:33:01,720 DRIVER FOR THE UNDERLYING 5122 03:33:01,720 --> 03:33:03,440 CENTRAL SENSITIZATION, WHAT IS 5123 03:33:03,440 --> 03:33:03,960 SECONDARY MANIFESTATION. 5124 03:33:03,960 --> 03:33:07,200 >>I WOULD JUST LIKE TO BRING UP 5125 03:33:07,200 --> 03:33:12,240 A QUESTION FOLLOWING UP TO 5126 03:33:12,240 --> 03:33:14,840 VALENTINE'S A INTERESTING 5127 03:33:14,840 --> 03:33:18,440 PRESENTATION, SHE PRESENTED 5128 03:33:18,440 --> 03:33:19,520 SALIENT MAPS, CAN OCCUR BY 5129 03:33:19,520 --> 03:33:22,600 CHANCE WITH THE CHALLENGES OF 5130 03:33:22,600 --> 03:33:25,080 THE IMAGE ANALYSIS PERCEIVED BUT 5131 03:33:25,080 --> 03:33:29,400 MOVING BEYOND WHAT YOU ARE 5132 03:33:29,400 --> 03:33:32,560 MENTIONING OF BINARY PAIN VERSUS 5133 03:33:32,560 --> 03:33:35,320 NO PAIN, IS IT POSSIBLE TO FOCUS 5134 03:33:35,320 --> 03:33:36,640 ON TESTING CORRELATIONS WITH 5135 03:33:36,640 --> 03:33:40,080 PAIN LEVELS IN THE ASSOCIATED 5136 03:33:40,080 --> 03:33:42,440 COMORBIDITIES WHICH I THINK IS A 5137 03:33:42,440 --> 03:33:48,640 NEEDED STEP, RIGHT? 5138 03:33:48,640 --> 03:33:49,200 ANY COMMENTS, VALENTINA? 5139 03:33:49,200 --> 03:33:52,600 >>THERE IS -- IT'S A TRICKY 5140 03:33:52,600 --> 03:33:56,440 BECAUSE THEN YOU GO BACK TO THE 5141 03:33:56,440 --> 03:34:00,720 MOVING TARGET OF GROUND TRUTH 5142 03:34:00,720 --> 03:34:03,120 BECAUSE -- IN THAT SPECIFIC 5143 03:34:03,120 --> 03:34:06,640 PROJECT, WE CHOOSE CHRONIC PAIN, 5144 03:34:06,640 --> 03:34:12,440 PRESENCE OF CHRONIC PAIN IN 5145 03:34:12,440 --> 03:34:16,400 PARTICULAR, CHRONIC PAIN AS 5146 03:34:16,400 --> 03:34:18,040 PROLONGATED PERIOD OF TIME, THAT 5147 03:34:18,040 --> 03:34:22,480 MAKES THE OUTCOME WAY MORE 5148 03:34:22,480 --> 03:34:22,920 RELIABLE. 5149 03:34:22,920 --> 03:34:26,880 AND IF YOU START MOVING FROM 5150 03:34:26,880 --> 03:34:29,480 THAT TO A CONTINUOUS PAIN, YOU 5151 03:34:29,480 --> 03:34:33,440 HAVE SO MUCH SUBJECTIVITY GOING 5152 03:34:33,440 --> 03:34:35,120 INTO THE PICTURE, AND YESTERDAY 5153 03:34:35,120 --> 03:34:36,760 WAS SOME INTERESTING TALKS AND 5154 03:34:36,760 --> 03:34:40,240 SOME WORK DOING ALSO HERE AT 5155 03:34:40,240 --> 03:34:43,080 UCSF ON THE LOWER BACK PAIN 5156 03:34:43,080 --> 03:34:47,680 PROJECT TO TRY TO OBJECTIFY 5157 03:34:47,680 --> 03:34:49,400 PAIN, FUNCTIONAL MRI, FUNCTIONAL 5158 03:34:49,400 --> 03:34:50,760 CONNECTIVITY INTO THE PICTURE, 5159 03:34:50,760 --> 03:34:52,800 SO WHEN WE START GOING TO LEVEL 5160 03:34:52,800 --> 03:34:55,800 OF PAIN I THINK WE NEED TO ALSO 5161 03:34:55,800 --> 03:35:01,880 WORK ON MAKE THE OUTCOME MORE 5162 03:35:01,880 --> 03:35:03,120 RELIABLE THAN SUBJECT 5163 03:35:03,120 --> 03:35:04,960 PATIENT-REPORTED LEVEL OF PAIN. 5164 03:35:04,960 --> 03:35:08,800 AND EVERYTHING THAT WE HEARD 5165 03:35:08,800 --> 03:35:11,680 YESTERDAY AND AS I SAID SOME 5166 03:35:11,680 --> 03:35:14,280 WORK WE'RE DOING ON FUNCTIONAL 5167 03:35:14,280 --> 03:35:15,280 CONNECTIVITY INTO THE PICTURE, 5168 03:35:15,280 --> 03:35:18,200 MIGHT HELP, MIGHT NOT BE THE 5169 03:35:18,200 --> 03:35:23,160 FINAL RESULT, BUT IT MIGHT HELP 5170 03:35:23,160 --> 03:35:25,240 >>I FEEL LIKE I'M CONSTANTLY 5171 03:35:25,240 --> 03:35:26,760 DAUNTED ABOUT THIS QUESTION 5172 03:35:26,760 --> 03:35:30,640 ABOUT HOW DO YOU IDENTIFY PAIN 5173 03:35:30,640 --> 03:35:32,480 SOURCES BECAUSE PAIN, I MEAN, IT 5174 03:35:32,480 --> 03:35:36,080 CAN COME FROM SO MANY DIRECTIONS 5175 03:35:36,080 --> 03:35:38,360 IN TERMS OF, YOU KNOW, TRYING -- 5176 03:35:38,360 --> 03:35:41,560 THERE ARE GREAT STUDIES ON 5177 03:35:41,560 --> 03:35:43,520 NEUROCONNECTIVITY, HOW THAT 5178 03:35:43,520 --> 03:35:46,080 RELATES TO NOCICEPTIVE VERSUS 5179 03:35:46,080 --> 03:35:49,360 NEUROPATHIC VERSUS OTHER TIMES 5180 03:35:49,360 --> 03:35:50,640 -- TYPES OF PAIN. 5181 03:35:50,640 --> 03:35:51,440 SOMEONE MAY HAVE PAIN TWICE A 5182 03:35:51,440 --> 03:35:53,520 WEEK AND THEY ARE SAYING I'VE 5183 03:35:53,520 --> 03:35:55,600 GOT THIS PAIN, AND THAT'S VERY 5184 03:35:55,600 --> 03:35:57,640 DIFFERENT THAN SOMEONE WHO HAS 5185 03:35:57,640 --> 03:36:00,200 HAD EIGHT OUT OF TEN PAIN FOR 5186 03:36:00,200 --> 03:36:01,040 FIVE YEARS STRAIGHT. 5187 03:36:01,040 --> 03:36:03,480 AND SO IT SEEMS LIKE FOR ALL OF 5188 03:36:03,480 --> 03:36:05,920 THESE WE ARE NOT EQUIPPED TO 5189 03:36:05,920 --> 03:36:07,320 SORT OF SAY THIS IS THE SOURCE 5190 03:36:07,320 --> 03:36:08,320 OF YOUR PAIN. 5191 03:36:08,320 --> 03:36:11,800 IT HAS TO BE MORE DIRECTED FROM 5192 03:36:11,800 --> 03:36:15,520 THE CLINICAL PRESENTATION AND 5193 03:36:15,520 --> 03:36:17,760 THE MORE WE CAN TARGET, YOU 5194 03:36:17,760 --> 03:36:21,120 KNOW, OUR IMAGING METHODS AND 5195 03:36:21,120 --> 03:36:24,400 ESPECIALLY ANALYSIS METHODS 5196 03:36:24,400 --> 03:36:25,200 TOWARDS A PARTICULAR 5197 03:36:25,200 --> 03:36:26,400 PRESENTATION, I THINK THE BETTER 5198 03:36:26,400 --> 03:36:29,480 THESE WILL BE. 5199 03:36:29,480 --> 03:36:31,120 BUT I MEAN IT SEEMS TOO DAUNTING 5200 03:36:31,120 --> 03:36:33,200 TO SAY THIS PERSON IS COMING 5201 03:36:33,200 --> 03:36:35,720 WITH KNEE PAIN, IMAGING MIGHT BE 5202 03:36:35,720 --> 03:36:36,600 HELPFUL TO PARTICULARLY RULE OUT 5203 03:36:36,600 --> 03:36:39,280 BUT THE IDEA IS LIKE WE'RE GOING 5204 03:36:39,280 --> 03:36:40,880 TO BE RELIABLY LIKE DIAGNOSING 5205 03:36:40,880 --> 03:36:42,840 THE SOURCE OF PAIN SEEMS REALLY 5206 03:36:42,840 --> 03:36:44,600 FAR OFF AT THE MOMENT, UNTIL WE 5207 03:36:44,600 --> 03:36:45,720 CAN SORT OF BETTER CLASSIFY 5208 03:36:45,720 --> 03:36:47,000 THESE PEOPLE COMING IN AND 5209 03:36:47,000 --> 03:36:49,640 BETTER FIT THEM TO THE 5210 03:36:49,640 --> 03:36:52,600 APPROPRIATE, YOU KNOW, MODEL OR 5211 03:36:52,600 --> 03:36:54,240 WHATEVER IT MAY BE, THAT CAN 5212 03:36:54,240 --> 03:36:56,160 HELP WITH THAT. 5213 03:36:56,160 --> 03:36:57,960 BUT TO JUST BROADLY KNEE PAIN 5214 03:36:57,960 --> 03:36:59,280 WILL BE REALLY TOUGH TO 5215 03:36:59,280 --> 03:37:04,760 DETERMINE ANY MODEL FOR. 5216 03:37:04,760 --> 03:37:06,920 >>YEAH, AND THE TECHNOLOGY, NOT 5217 03:37:06,920 --> 03:37:09,640 NECESSARILY WILL SOLVE THE 5218 03:37:09,640 --> 03:37:13,360 PROBLEM BUT CAN SURFACE A LOT OF 5219 03:37:13,360 --> 03:37:15,280 THE SHORTCOMINGS OF QUESTIONER 5220 03:37:15,280 --> 03:37:17,120 AND THE WAY WE ASSESS PAIN. 5221 03:37:17,120 --> 03:37:24,200 THE MODEL THAT I PRESENTED TODAY 5222 03:37:24,200 --> 03:37:26,080 HAD SUPER SIGNIFICANT BIAS IN 5223 03:37:26,080 --> 03:37:28,720 THE NUMBER OF TRUE POSITIVE AND 5224 03:37:28,720 --> 03:37:30,240 THE FIRST PREDICTOR OF BEING 5225 03:37:30,240 --> 03:37:31,360 TRUE POSITIVE WAS RACE, WHICH 5226 03:37:31,360 --> 03:37:33,200 MEANS THE MODEL LOOK AT YOUR 5227 03:37:33,200 --> 03:37:35,480 KNEE, THINKS YOU SHOULD REPORT 5228 03:37:35,480 --> 03:37:36,920 PAIN, BUT THE QUESTIONER SAID 5229 03:37:36,920 --> 03:37:40,040 THAT THE PAIN WAS NOT REPORTED. 5230 03:37:40,040 --> 03:37:44,800 AND THOSE TYPE OF THINGS CAN BE 5231 03:37:44,800 --> 03:37:47,720 QUANTIFIED, QUANTIFIED AND VERY 5232 03:37:47,720 --> 03:37:48,360 STRONGLY STATISTICALLY ASSESSED 5233 03:37:48,360 --> 03:37:51,360 WITH THE TECHNOLOGY THAT WE ARE 5234 03:37:51,360 --> 03:37:52,240 DEVELOPING. 5235 03:37:52,240 --> 03:37:54,120 EVERYTHING ABOUT YOUR DATA 5236 03:37:54,120 --> 03:37:56,080 PROFILE SAID SOMETHING, AND 5237 03:37:56,080 --> 03:38:03,040 YOU'RE SAYING SOMETHING ELSE. 5238 03:38:03,040 --> 03:38:04,280 SO TO UNDERSTAND THIS 5239 03:38:04,280 --> 03:38:09,280 DISCREPANCY CAN HELP US 5240 03:38:09,280 --> 03:38:11,240 DEFINITELY UNDERSTANDING THE 5241 03:38:11,240 --> 03:38:13,120 SHORT COMING ALSO OF OUR 5242 03:38:13,120 --> 03:38:15,720 ASSESSMENT, ASSESSMENT OF PAIN, 5243 03:38:15,720 --> 03:38:19,400 THAT IS ABSOLUTELY, YOU KNOW, 5244 03:38:19,400 --> 03:38:22,680 FULL OF SHORTCOMINGS, IN A WAY. 5245 03:38:22,680 --> 03:38:23,400 5246 03:38:23,400 --> 03:38:27,040 >>THE NEXT QUESTION IS KIND OF 5247 03:38:27,040 --> 03:38:30,040 RELATED TO THE POINT RICCARDO 5248 03:38:30,040 --> 03:38:33,360 BROUGHT UP EARLIER, IN THE 5249 03:38:33,360 --> 03:38:36,360 CLINICAL VALIDATION OF THE 5250 03:38:36,360 --> 03:38:39,400 QUANTITATIVE MR WE USUALLY, YOU 5251 03:38:39,400 --> 03:38:40,600 KNOW, GIVEN THE FACT GROUND 5252 03:38:40,600 --> 03:38:44,640 TRUTH IS NOT THAT RELIABLE 5253 03:38:44,640 --> 03:38:47,480 SOMETIMES, AND BASED ON SURGICAL 5254 03:38:47,480 --> 03:38:49,400 REPORT MAY NOT BE CONSISTENT 5255 03:38:49,400 --> 03:38:50,560 ACROSS PATIENT OR DOCTORS, 5256 03:38:50,560 --> 03:38:52,960 SOMETIMES THERE ARE LACK OF 5257 03:38:52,960 --> 03:38:59,000 DETAIL AND SO WHAT COULD BE 5258 03:38:59,000 --> 03:39:01,400 ALTERNATIVE COMPARE IMAGING 5259 03:39:01,400 --> 03:39:02,400 BIOMARKERS AGAINST OBJECTIVE 5260 03:39:02,400 --> 03:39:09,280 QUANTITATIVE GROUND TRUTH DATA. 5261 03:39:09,280 --> 03:39:11,440 >>IN MY OPINION IT WOULD BE 5262 03:39:11,440 --> 03:39:14,400 NICE TO USE LIKE TRUE BIOLOGICAL 5263 03:39:14,400 --> 03:39:16,720 MEASURES LIKE HISTOLOGY OR 5264 03:39:16,720 --> 03:39:19,120 PATHOLOGY, AND TRY TO CONNECT 5265 03:39:19,120 --> 03:39:20,640 ALL THESE THINGS ON A MULTIPLE 5266 03:39:20,640 --> 03:39:22,640 SCALE TO THE OTHER. 5267 03:39:22,640 --> 03:39:29,400 AND TRY TO MAYBE DESIGN OUR 5268 03:39:29,400 --> 03:39:32,040 IMAGING ACQUISITION AND PROBE 5269 03:39:32,040 --> 03:39:33,360 THESE PARTICULAR THINGS IN 5270 03:39:33,360 --> 03:39:35,320 HISTOLOGY AND PATHOLOGY WITH MRI 5271 03:39:35,320 --> 03:39:36,920 WHICH CAN BE DONE, YOU JUST NEED 5272 03:39:36,920 --> 03:39:39,680 A LOT OF DATA TO UNDERSTAND HOW 5273 03:39:39,680 --> 03:39:42,960 TO TRAIN THEM AND USE, NOT JUST 5274 03:39:42,960 --> 03:39:44,720 USE WITH GROUND TRUTH BUT TRY TO 5275 03:39:44,720 --> 03:39:46,120 PHYSICALLY UNDERSTAND WHAT THESE 5276 03:39:46,120 --> 03:39:47,480 PARAMETERS MEAN AT THE 5277 03:39:47,480 --> 03:39:50,320 BIOLOGICAL LEVEL BY USING MAYBE 5278 03:39:50,320 --> 03:39:51,320 MACHINE LEARNING TO DEVELOP 5279 03:39:51,320 --> 03:39:52,960 MODELS WHICH LOOK AT THE 5280 03:39:52,960 --> 03:39:55,360 MULTIPLE SCALES. 5281 03:39:55,360 --> 03:39:56,320 LIKE SOMETHING LIKE COMBINING 5282 03:39:56,320 --> 03:39:59,280 ALL THESE DIFFERENT TYPE OF DATA 5283 03:39:59,280 --> 03:40:00,480 TOGETHER AND TRAIN TO UNDERSTAND 5284 03:40:00,480 --> 03:40:04,120 WHAT THEY MEAN SO YOU DON'T NEED 5285 03:40:04,120 --> 03:40:06,320 ANYMORE SUBJECTIVE SURGICAL 5286 03:40:06,320 --> 03:40:07,720 REPORT, YOU CAN SEE THIS 5287 03:40:07,720 --> 03:40:11,560 DISTRIBUTION OF MY MR PARAMETERS 5288 03:40:11,560 --> 03:40:14,760 MEANS THAT THIS CONCENTRATION OF 5289 03:40:14,760 --> 03:40:15,360 LIGANDS, IF THE COLLAGEN 5290 03:40:15,360 --> 03:40:18,000 METRICS, IF DONE THIS WAY, AT 5291 03:40:18,000 --> 03:40:18,680 THIS LEVEL. 5292 03:40:18,680 --> 03:40:20,000 AND THIS CAN BE DONE. 5293 03:40:20,000 --> 03:40:22,400 WE DON'T HAVE THE DATA YET BUT 5294 03:40:22,400 --> 03:40:23,040 IN PRINCIPLE IT'S NOT 5295 03:40:23,040 --> 03:40:25,680 IMPOSSIBLE. 5296 03:40:25,680 --> 03:40:27,240 >>MAY I ASK A FOLLOW-UP 5297 03:40:27,240 --> 03:40:27,880 QUESTION TO THAT? 5298 03:40:27,880 --> 03:40:30,760 I THINK I'M A LITTLE BIT MORE 5299 03:40:30,760 --> 03:40:34,040 SKEPTICAL HERE THAT T2 AND T1, 5300 03:40:34,040 --> 03:40:37,280 EVEN SOME OF THE OTHER CARTILAGE 5301 03:40:37,280 --> 03:40:38,200 METRICS, THEY REALLY FEEL LIKE 5302 03:40:38,200 --> 03:40:44,120 ARE NEVER GOING TO REALLY BE 5303 03:40:44,120 --> 03:40:44,720 SPECIFIC TO ANY PARTICULAR 5304 03:40:44,720 --> 03:40:46,040 METRIC, EVEN IF YOU ACQUIRE 5305 03:40:46,040 --> 03:40:47,280 MULTIPLE I DON'T THINK YOU EVER 5306 03:40:47,280 --> 03:40:49,560 GET TO THE POINT YOU'RE GOING 5307 03:40:49,560 --> 03:40:53,400 HAVE THIS KIND OF COLLAGEN 5308 03:40:53,400 --> 03:40:54,280 CHANGE, PROTEOGLYCAN CHANGE. 5309 03:40:54,280 --> 03:40:56,800 IS THERE A WAY TO REFRAME THAT 5310 03:40:56,800 --> 03:40:59,560 QUESTION TO REALLY SORT OF SAY, 5311 03:40:59,560 --> 03:41:03,520 I DON'T KNOW , WHAT IS THE STUDY 5312 03:41:03,520 --> 03:41:05,880 THAT'S NEEDED WHEN YOU SEE A 5313 03:41:05,880 --> 03:41:09,280 CHANGE IN T2, WHATEVER IT MAY BE 5314 03:41:09,280 --> 03:41:13,200 THAT'S GOING TO BE USEFUL 5315 03:41:13,200 --> 03:41:13,520 CLINICALLY? 5316 03:41:13,520 --> 03:41:17,360 BECAUSE I FEEL LIKE WE'VE 5317 03:41:17,360 --> 03:41:19,240 FOCUSED SO LONG ON PROTEOGLYCAN 5318 03:41:19,240 --> 03:41:20,960 COLLAGEN CHANGES, I DON'T SEE 5319 03:41:20,960 --> 03:41:23,600 THOSE AS BEING SPECIFIC TO 5320 03:41:23,600 --> 03:41:26,200 EITHER ONE BUT STUDIES SAY THEY 5321 03:41:26,200 --> 03:41:29,400 ARE PREDICTIVE OF FUTURE DISEASE 5322 03:41:29,400 --> 03:41:30,720 PROGRESSION, CARTILAGE, IS THAT 5323 03:41:30,720 --> 03:41:34,320 GOOD ENOUGH, LIKE WHAT ELSE DO 5324 03:41:34,320 --> 03:41:39,680 WE NEED TO SHOW FOR THEM TO BE 5325 03:41:39,680 --> 03:41:41,680 UTILIZED IN, AGAIN, APPLICATION 5326 03:41:41,680 --> 03:41:44,280 NEEDS TO BE DETERMINED 5327 03:41:44,280 --> 03:41:44,560 CLINICALLY. 5328 03:41:44,560 --> 03:41:46,480 >>I AGREE. 5329 03:41:46,480 --> 03:41:49,120 I'M NOT SAYING SPECIFIC BUT ONLY 5330 03:41:49,120 --> 03:41:51,040 A FEW ARE SPECIFIC, SODIUM 5331 03:41:51,040 --> 03:41:53,480 IMAGING IS SPECIFIC TO GLYCANS, 5332 03:41:53,480 --> 03:41:59,040 ALL THE OTHERS ARE A MIX LIKE 5333 03:41:59,040 --> 03:42:04,840 BLT 1 IT'S ALMOST POSSIBLE MAYBE 5334 03:42:04,840 --> 03:42:08,240 T1 IN TISSUES, IF YOU CAN BUILD 5335 03:42:08,240 --> 03:42:11,640 A MODEL THAT SEE HOW CAN THAT BE 5336 03:42:11,640 --> 03:42:13,840 TRANSLATED TO HISTOLOGY OR 5337 03:42:13,840 --> 03:42:16,880 PATHOLOGY, THEN MAYBE YOU CANNOT 5338 03:42:16,880 --> 03:42:18,720 SAY SPECIFICALLY THIS PARAMETER 5339 03:42:18,720 --> 03:42:22,480 BUT IF IMAGE ACQUISITION WITHOUT 5340 03:42:22,480 --> 03:42:23,680 EVEN BUILDING PARAMETER MAP CAN 5341 03:42:23,680 --> 03:42:25,840 GO TO HISTOLOGY AND SAY IT GIVES 5342 03:42:25,840 --> 03:42:26,960 ME THIS ACTION OF THE 5343 03:42:26,960 --> 03:42:30,360 INFORMATION, WE KNOW IF IT'S 5344 03:42:30,360 --> 03:42:33,080 ONLY GLYCAN LOSS THEN IT'S 5345 03:42:33,080 --> 03:42:34,760 REVERSIBLE, IF THE COLLAGEN 5346 03:42:34,760 --> 03:42:35,720 MATRIX IS GOING BAD THERE'S 5347 03:42:35,720 --> 03:42:37,240 NOTHING CAN YOU DO EVEN IF THE 5348 03:42:37,240 --> 03:42:38,880 CARTILAGE LOOKS OKAY YOU'RE NOT 5349 03:42:38,880 --> 03:42:43,520 GOING TO REPAIR IT, UNTIL PEOPLE 5350 03:42:43,520 --> 03:42:45,520 FIND LIKE HOW TO MAKE CARTILAGE 5351 03:42:45,520 --> 03:42:47,320 REPAIR, RIGHT? 5352 03:42:47,320 --> 03:42:49,200 WE WERE SAYING BEFORE, I THINK 5353 03:42:49,200 --> 03:42:54,040 WHAT WE NEED TO REALLY PROVE, 5354 03:42:54,040 --> 03:42:57,200 IMPORTANCE OF QUANTITATIVE MRI, 5355 03:42:57,200 --> 03:42:59,400 BUT, YEAH, I AGREE THEY ARE NOT 5356 03:42:59,400 --> 03:43:01,360 SPECIFIC, YOU COMBINE THEM YOU 5357 03:43:01,360 --> 03:43:03,920 CAN GET INFORMATION OUT OF THEM. 5358 03:43:03,920 --> 03:43:05,560 >>I GUESS MY THOUGHT IS MAYBE 5359 03:43:05,560 --> 03:43:07,400 WE NEED TO TRY TO GO BACK TO 5360 03:43:07,400 --> 03:43:12,320 MORE OF THE BASIC VALIDATION 5361 03:43:12,320 --> 03:43:13,400 APPROACH, THE BENCH-TIME 5362 03:43:13,400 --> 03:43:13,840 VALIDATIONS METHODS. 5363 03:43:13,840 --> 03:43:17,480 I MEAN, THESE GO BACK TO LIKE 5364 03:43:17,480 --> 03:43:18,160 THE QUANTITATIVE WATER QUANTITY 5365 03:43:18,160 --> 03:43:23,080 IF 5366 03:43:23,080 --> 03:43:24,480 QUANTIFICATION, BENCH GOLD 5367 03:43:24,480 --> 03:43:24,920 STANDARDS. 5368 03:43:24,920 --> 03:43:27,360 AND SO I FEEL LIKE NOWADAYS WE 5369 03:43:27,360 --> 03:43:29,920 LOSE THAT A LITTLE BIT, WE THINK 5370 03:43:29,920 --> 03:43:31,800 IT'S TOO FAR SEPARATED FROM WHAT 5371 03:43:31,800 --> 03:43:34,760 WE SEE IN THE IN VIVO TISSUE 5372 03:43:34,760 --> 03:43:35,400 CLINICALLY. 5373 03:43:35,400 --> 03:43:38,480 ONCE UPON A TIME THAT DID WORK. 5374 03:43:38,480 --> 03:43:42,080 THERE'S ACTUAL QUANTITATIVE M.R. 5375 03:43:42,080 --> 03:43:44,320 TECHNIQUES VALIDATED IN PHANTOMS 5376 03:43:44,320 --> 03:43:46,120 AND WITH WELL-CONTROLLED BENCH 5377 03:43:46,120 --> 03:43:46,640 EXPERIMENTS. 5378 03:43:46,640 --> 03:43:49,080 SO I WONDER IF SOME METRICS CAN 5379 03:43:49,080 --> 03:43:51,880 BE DISTILLED BACK TO SIMPLE 5380 03:43:51,880 --> 03:43:53,040 BENCH VALIDATION APPROACHES, NOT 5381 03:43:53,040 --> 03:43:53,480 ALL CAN. 5382 03:43:53,480 --> 03:43:57,360 HOW DO YOU MAKE A PHANTOM THAT'S 5383 03:43:57,360 --> 03:43:59,880 GOT GOLD STANDARD T1 ROW, THAT'S 5384 03:43:59,880 --> 03:44:02,800 A GOOD PHYSICS OR CHEMISTRY 5385 03:44:02,800 --> 03:44:03,080 QUESTION. 5386 03:44:03,080 --> 03:44:04,360 BUT I WONDER IF THERE'S MAYBE 5387 03:44:04,360 --> 03:44:06,640 SOME SORT OF GOING BACK IN TIME 5388 03:44:06,640 --> 03:44:08,640 THAT MIGHT HELP A LITTLE BIT 5389 03:44:08,640 --> 03:44:11,400 WITH THIS MASSIVE FLUX OF 5390 03:44:11,400 --> 03:44:12,680 QUANTITATIVE TECHNIQUES THAT WE 5391 03:44:12,680 --> 03:44:14,280 HAVE NOW THAT DO NEED TO GET 5392 03:44:14,280 --> 03:44:16,760 VALIDATED SOMEHOW. 5393 03:44:16,760 --> 03:44:17,440 5394 03:44:17,440 --> 03:44:19,320 >>YEAH, AND MAYBE WHAT I'M 5395 03:44:19,320 --> 03:44:21,400 ABOUT TO SAY IS ALL ON THE OTHER 5396 03:44:21,400 --> 03:44:23,360 SIDE OF THE SPECTRUM FROM WHAT 5397 03:44:23,360 --> 03:44:27,080 KEVIN IS SAYING, HOW SIMILAR TO 5398 03:44:27,080 --> 03:44:33,000 WHAT RICCARDO WAS SAYING. 5399 03:44:33,000 --> 03:44:35,520 IN OTHER APPLICATION, WE CAN SEE 5400 03:44:35,520 --> 03:44:38,880 MODELS, FOR EXAMPLE, IN BRAIN 5401 03:44:38,880 --> 03:44:43,760 CANCER, WE CAN SEE MACHINE 5402 03:44:43,760 --> 03:44:44,800 LEARNING MODEL, TAKING INPUT, 5403 03:44:44,800 --> 03:44:49,200 T1, T2, AND FLARE, AND DO 5404 03:44:49,200 --> 03:44:50,720 PROJECTION OF GENETIC SUBTYPE OF 5405 03:44:50,720 --> 03:44:52,880 BRAIN TUMOR. 5406 03:44:52,880 --> 03:44:54,000 AND THERE'S NOTHING SPECIFIC OR 5407 03:44:54,000 --> 03:44:56,400 SENSITIVE IN THE SIGNAL OF T1 OR 5408 03:44:56,400 --> 03:44:59,800 SIGNAL OF THE FLARE THAT IS 5409 03:44:59,800 --> 03:45:03,440 DIRECTLY RELATED TO THE GENETIC 5410 03:45:03,440 --> 03:45:05,360 SUBTYPE, BUT IS ALL THE ADDITION 5411 03:45:05,360 --> 03:45:08,760 OF ENTIRE -- THE SHAPE OF THE 5412 03:45:08,760 --> 03:45:11,280 TUMOR AND THE SIGNAL, AND ALL 5413 03:45:11,280 --> 03:45:13,680 THE PICTURE TOGETHER ACTUALLY 5414 03:45:13,680 --> 03:45:14,680 BECOME PREDICTIVE. 5415 03:45:14,680 --> 03:45:17,080 SO MAYBE SPINE, IF THEY ARE NOT 5416 03:45:17,080 --> 03:45:19,280 DIRECTLY -- IF THE SINGLE VALUE 5417 03:45:19,280 --> 03:45:24,400 OF THE SINGLE VOXEL OF A T2 5418 03:45:24,400 --> 03:45:26,280 RELAXATION TIME DOES NOT 5419 03:45:26,280 --> 03:45:27,040 CORRELATE WITH COLLAGEN, IT'S 5420 03:45:27,040 --> 03:45:27,600 FINE. 5421 03:45:27,600 --> 03:45:30,640 IF WE CAN DO WHAT RICCARDO WAS 5422 03:45:30,640 --> 03:45:31,960 SAYING, PREDICTING HISTOLOGY MAP 5423 03:45:31,960 --> 03:45:34,280 FROM ALL OF THEM, AND LET 5424 03:45:34,280 --> 03:45:35,120 EVERYTHING CONTRIBUTE THE SHAPE 5425 03:45:35,120 --> 03:45:39,720 OF THE BONE WITH THE STATUS OF 5426 03:45:39,720 --> 03:45:44,120 CARTILAGE, THE T2 MAP, WHATEVER 5427 03:45:44,120 --> 03:45:44,880 YOU CAN ACQUIRE. 5428 03:45:44,880 --> 03:45:48,720 AND CAN ACCEPT THE FACT THE 5429 03:45:48,720 --> 03:45:51,800 SINGLE VOXEL DIDN'T CORRELATE, 5430 03:45:51,800 --> 03:45:52,480 WILL NEVER CORRELATE. 5431 03:45:52,480 --> 03:45:54,520 >>TO PUSH THIS TO EXTREME ONCE 5432 03:45:54,520 --> 03:45:56,360 WE HAVE FINGERPRINTING POSITION 5433 03:45:56,360 --> 03:46:00,520 YOU CAN OPTIMIZE, YOU DON'T EVEN 5434 03:46:00,520 --> 03:46:00,840 NEED IMAGES. 5435 03:46:00,840 --> 03:46:02,440 THE INFORMATION YOU USE TO 5436 03:46:02,440 --> 03:46:04,480 CONSTRUCT IMAGES ARE IN THE 5437 03:46:04,480 --> 03:46:04,840 SIGNAL. 5438 03:46:04,840 --> 03:46:06,520 AND ACTUALLY MORE INFORMATION 5439 03:46:06,520 --> 03:46:08,280 WHICH WE THROW AWAY, YOU JUST 5440 03:46:08,280 --> 03:46:10,920 BUILD A MODEL, USE THE 5441 03:46:10,920 --> 03:46:15,480 ACQUISITION, AND GET FOR 5442 03:46:15,480 --> 03:46:21,200 HISTOLOGICAL IMAGES YOU NEED. 5443 03:46:21,200 --> 03:46:23,520 >>I HAVE A FEW COMMENTS. 5444 03:46:23,520 --> 03:46:24,520 KEVIN, I TOTALLY AGREE. 5445 03:46:24,520 --> 03:46:26,320 AT THE SAME TIME THOSE ARE 5446 03:46:26,320 --> 03:46:29,400 REALLY HARD TO DO, RIGHT? 5447 03:46:29,400 --> 03:46:36,240 EX VIVO EXPERIMENTS TO LOOK AT 5448 03:46:36,240 --> 03:46:38,440 PROTEOGLYCAN CONTENT DEGRADE THE 5449 03:46:38,440 --> 03:46:39,200 CARTILAGE, DOING MORE. 5450 03:46:39,200 --> 03:46:42,400 IT'S REALLY HARD TO COME UP WITH 5451 03:46:42,400 --> 03:46:44,800 AN EX VIVO TEST TO CORRELATE 5452 03:46:44,800 --> 03:46:46,120 WITH PARAMETERS BECAUSE WHEN ONE 5453 03:46:46,120 --> 03:46:48,520 THING CHANGES, A BUNCH OF THINGS 5454 03:46:48,520 --> 03:46:51,480 CHANGE, AND FIGURING OUT WHICH 5455 03:46:51,480 --> 03:46:53,760 ONE IS DRIVING YOUR QUANTITATIVE 5456 03:46:53,760 --> 03:46:54,560 IMAGING METRIC IS DIFFICULT. 5457 03:46:54,560 --> 03:46:58,400 ONCE YOU GO TO IN VIVO AND 5458 03:46:58,400 --> 03:47:00,240 INCREASE LIKE INTRODUCE LIKE 5459 03:47:00,240 --> 03:47:02,840 BLOOD FLOW AND SYNOVIAL 5460 03:47:02,840 --> 03:47:04,200 DIFFUSION, PERFUSION TO THESE, 5461 03:47:04,200 --> 03:47:05,840 SOME 6 THESE STRUCTURES, IT'S A 5462 03:47:05,840 --> 03:47:06,680 REALLY BIG CHALLENGE. 5463 03:47:06,680 --> 03:47:09,640 SORT OF THE FLIP SIDE IS EVEN IF 5464 03:47:09,640 --> 03:47:11,480 YOU COULD DO THAT, I DON'T THINK 5465 03:47:11,480 --> 03:47:12,840 WE HAVE A GOOD ENOUGH 5466 03:47:12,840 --> 03:47:16,440 UNDERSTANDING OF LIKE IF YOU HAD 5467 03:47:16,440 --> 03:47:17,760 HISTOLOGY ON EVERYONE'S 5468 03:47:17,760 --> 03:47:19,080 CARTILAGE WOULD THAT REALLY 5469 03:47:19,080 --> 03:47:20,360 DRIVE CLINICAL DECISION MAKING 5470 03:47:20,360 --> 03:47:21,040 RIGHT NOW? 5471 03:47:21,040 --> 03:47:23,320 I'M NOT CLEAR THAT WE KNOW 5472 03:47:23,320 --> 03:47:24,760 ENOUGH ABOUT CHANGES TO 5473 03:47:24,760 --> 03:47:27,160 CARTILAGE TO MAKE A DECISION 5474 03:47:27,160 --> 03:47:30,320 THAT LIKE THIS PERSON NEEDS 5475 03:47:30,320 --> 03:47:30,760 PREEMPTIVE. 5476 03:47:30,760 --> 03:47:33,400 I'M SURE IT WOULD BE, YOU KNOW, 5477 03:47:33,400 --> 03:47:35,720 REALLY HELPFUL, BUT THAT'S WHY I 5478 03:47:35,720 --> 03:47:37,760 WONDER, LIKE, AGAIN, YOU KNOW, 5479 03:47:37,760 --> 03:47:39,720 PUTTING THESE IN SITUATIONS 5480 03:47:39,720 --> 03:47:41,480 WHERE THEY MIGHT HAVE FUTURE 5481 03:47:41,480 --> 03:47:43,160 APPLICATION JUST ON THE CHANGES, 5482 03:47:43,160 --> 03:47:46,080 AND MAYBE NOT SO MUCH ON THE 5483 03:47:46,080 --> 03:47:51,920 CORRELATES WILL PROBABLY GO 5484 03:47:51,920 --> 03:47:54,840 POTENTIALLY FURTHER THAN HIS 5485 03:47:54,840 --> 03:47:55,520 DISTINCT HISTOLOGICAL CORRELATES 5486 03:47:55,520 --> 03:47:57,360 WHICH I'M NOT SURE THAT WE CAN 5487 03:47:57,360 --> 03:47:59,120 GET. 5488 03:47:59,120 --> 03:47:59,240 5489 03:47:59,240 --> 03:48:02,520 >>THANK YOU. 5490 03:48:02,520 --> 03:48:05,680 ANOTHER QUESTION IS WE HAVE 5491 03:48:05,680 --> 03:48:07,080 TECHNOLOGY, EMERGING TECHNOLOGY 5492 03:48:07,080 --> 03:48:09,200 HERE, THE QUESTION IS HOW CAN 5493 03:48:09,200 --> 03:48:12,240 WE, YOU KNOW, HOW THE IMAGING 5494 03:48:12,240 --> 03:48:15,720 BIOMARKERS CAN BE INTEGRATED 5495 03:48:15,720 --> 03:48:18,280 WITH COMPUTATIONAL BIOMECHANICS 5496 03:48:18,280 --> 03:48:23,080 MODELS TO CREATE COMPLEX MODEL 5497 03:48:23,080 --> 03:48:26,160 TO ASSESS OR PREDICT SIMULATE AT 5498 03:48:26,160 --> 03:48:36,320 SCALES. 5499 03:48:37,440 --> 03:48:38,200 5500 03:48:38,200 --> 03:48:39,360 >>THAT'S A VERY IMPORTANT 5501 03:48:39,360 --> 03:48:39,600 QUESTION. 5502 03:48:39,600 --> 03:48:41,960 I DON'T KNOW IF WE HAVE ABILITY 5503 03:48:41,960 --> 03:48:43,240 TO DO THAT YET. 5504 03:48:43,240 --> 03:48:47,720 PART OF THE CHALLENGE AS WE WERE 5505 03:48:47,720 --> 03:48:50,880 DISCUSSING JUST NOW IS THAT WE 5506 03:48:50,880 --> 03:48:52,640 DON'T KNOW ENOUGH ABOUT THE 5507 03:48:52,640 --> 03:48:57,880 ENTIRE SYSTEM TO BE ABLE TO DO 5508 03:48:57,880 --> 03:48:59,440 THOSE KIND OF LINKAGES. 5509 03:48:59,440 --> 03:49:00,600 I'M CURIOUS TO HEAR WHAT OTHERS 5510 03:49:00,600 --> 03:49:02,400 HAVE TO SAY BUT THAT'S A 5511 03:49:02,400 --> 03:49:05,560 PRESSING NEED TO DEVELOP THAT. 5512 03:49:05,560 --> 03:49:07,320 5513 03:49:07,320 --> 03:49:11,560 >>YES, MY SENSE IS THAT STEP 5514 03:49:11,560 --> 03:49:13,920 ONE IN THE ACHIEVABLE, IN THE 5515 03:49:13,920 --> 03:49:16,000 FIRST INTEGRATION BETWEEN THIS 5516 03:49:16,000 --> 03:49:17,400 IMAGING TECHNIQUE AND 5517 03:49:17,400 --> 03:49:24,200 COMPUTATIONAL MODELING IS ON 5518 03:49:24,200 --> 03:49:26,600 PERSONALIZING BIOMECHANICS MODEL 5519 03:49:26,600 --> 03:49:30,000 ON ANATOMY OF PATIENTS, WITH MR 5520 03:49:30,000 --> 03:49:35,520 AND FIND, FOR EXAMPLE, IF ONE 5521 03:49:35,520 --> 03:49:39,920 HAS COMPLETE SEGMENTATION OF 5522 03:49:39,920 --> 03:49:41,760 VERTEBRAE, DISC, MUSCLE, CAN 5523 03:49:41,760 --> 03:49:44,040 HAVE LOADING MODEL THAT IS NOW 5524 03:49:44,040 --> 03:49:47,000 PERSONALIZED ON THE ACTUAL 5525 03:49:47,000 --> 03:49:52,720 ANATOMY OF THE PATIENT INSTEAD 5526 03:49:52,720 --> 03:49:57,440 OF USING GENERAL RULES, SO THAT 5527 03:49:57,440 --> 03:50:00,480 IS PROBABLY THE EASIEST -- 5528 03:50:00,480 --> 03:50:01,920 SOUNDS EASY BUT IT'S NOT, 5529 03:50:01,920 --> 03:50:04,240 EASIEST ENTRY LEVEL. 5530 03:50:04,240 --> 03:50:08,880 ONE IS TO MAKE THE END OF 5531 03:50:08,880 --> 03:50:10,920 COMPUTATIONAL MODEL PAPER MORE 5532 03:50:10,920 --> 03:50:15,760 THAN TWO, THREE SUBJECTS, AND 5533 03:50:15,760 --> 03:50:24,280 MAYBE WE CAN PERSONALIZE ON 5534 03:50:24,280 --> 03:50:27,560 ANATOMY OF REAL PATIENT INSTEAD 5535 03:50:27,560 --> 03:50:33,280 OF USING GENERAL ANATOMY FOR 5536 03:50:33,280 --> 03:50:34,040 BIOMECHANICS COMPUTATION 5537 03:50:34,040 --> 03:50:34,600 MODELING. 5538 03:50:34,600 --> 03:50:36,440 >>MAYBE I CAN COMMENT AS A 5539 03:50:36,440 --> 03:50:38,000 MECHANICAL ENGINEER HERE. 5540 03:50:38,000 --> 03:50:39,640 SO, THERE'S A TREMENDOUS AMOUNT 5541 03:50:39,640 --> 03:50:44,360 OF WORK IN OTHER NIH SPONSORED 5542 03:50:44,360 --> 03:50:45,760 SYMPOSIA ON SUBJECT-SPECIFIC 5543 03:50:45,760 --> 03:50:46,040 MODELING. 5544 03:50:46,040 --> 03:50:51,440 THE STANFORD HAS LED THE WAY 5545 03:50:51,440 --> 03:50:55,720 WITH THE SYMBIO PROJECT, 5546 03:50:55,720 --> 03:50:59,360 UNIVERSITY OF UTAH, GETTING 5547 03:50:59,360 --> 03:51:00,600 TOWARDS SUBJECT-SPECIFIC JOINT 5548 03:51:00,600 --> 03:51:03,080 LEVEL AND TISSUE MODELING. 5549 03:51:03,080 --> 03:51:08,440 AS YOU EXPECT, THE EXPENSE IS 5550 03:51:08,440 --> 03:51:10,520 GETTING THOSE SUBJECT-SPECIFIC 5551 03:51:10,520 --> 03:51:12,400 MODELS, INVOLVING EXPENSIVE 5552 03:51:12,400 --> 03:51:13,920 SEGMENTATION, MODEL 5553 03:51:13,920 --> 03:51:17,360 CONSTRUCTION, SO THE WORK HERE 5554 03:51:17,360 --> 03:51:20,280 SEEMS VERY CONDUCIVE TO 5555 03:51:20,280 --> 03:51:24,000 AUTOMATICALLY HAVE INPUTS FOR 5556 03:51:24,000 --> 03:51:24,720 THOSE SUBJECT-SPECIFIC MODELS, 5557 03:51:24,720 --> 03:51:27,000 REALLY GOING IN PARALLEL 5558 03:51:27,000 --> 03:51:28,920 PATHWAYS, VERY COMPLEMENTARY. 5559 03:51:28,920 --> 03:51:33,400 AND I COULD EXPECT TO HAVE 5560 03:51:33,400 --> 03:51:37,520 USEFUL SUBJECT-SPECIFIC MODELS 5561 03:51:37,520 --> 03:51:39,880 SIMILAR BUT READILY AVAILABLE 5562 03:51:39,880 --> 03:51:43,520 ULTIMATELY INTEGRATED IN 5563 03:51:43,520 --> 03:51:47,160 CLINICAL PATHWAY, NOT TOO FAR 5564 03:51:47,160 --> 03:51:47,360 ALONG. 5565 03:51:47,360 --> 03:51:50,760 >>SO I THINK WHAT SCOTT SAID 5566 03:51:50,760 --> 03:51:54,360 BRINGS UP THE ISSUE THAT SINCE 5567 03:51:54,360 --> 03:51:57,240 QUANTITATIVE MRI IS NOT 5568 03:51:57,240 --> 03:52:00,760 AVAILABLE CLINICALLY, IMAGE 5569 03:52:00,760 --> 03:52:03,000 ANALYSIS FOR MORPHOLOGICAL 5570 03:52:03,000 --> 03:52:04,160 IMAGING THAT INCLUDES 5571 03:52:04,160 --> 03:52:06,320 SEGMENTATION AND REGISTRATION 5572 03:52:06,320 --> 03:52:11,880 CRUCIAL FOR GENERALIZABLE AND 5573 03:52:11,880 --> 03:52:13,360 OPENLY AVAILABLE 5574 03:52:13,360 --> 03:52:15,880 PATIENT-SPECIFIC MODELS. 5575 03:52:15,880 --> 03:52:26,400 IN A A PRESENTATION, THE USE OF 5576 03:52:27,360 --> 03:52:28,760 OTHER METHODS FOR REGISTRATIONS 5577 03:52:28,760 --> 03:52:32,600 BUT DOES ANYBODY WANT TO COMMENT 5578 03:52:32,600 --> 03:52:36,600 ON WAYS OF DETERMINING PRECISION 5579 03:52:36,600 --> 03:52:39,360 OF THIS IMAGE FOR REGISTRATION 5580 03:52:39,360 --> 03:52:41,440 APPROACHES AND PARTICULARLY IF 5581 03:52:41,440 --> 03:52:44,200 WE'RE USING FOR REGISTRATION 5582 03:52:44,200 --> 03:52:47,960 METHODS SUCH AS ITERATIVE 5583 03:52:47,960 --> 03:52:50,560 CLOSEST POINTS, REGIONS IN TERMS 5584 03:52:50,560 --> 03:52:53,920 OF IMAGE ANALYSIS PERSPECTIVE 5585 03:52:53,920 --> 03:52:57,360 FOR AUTOMATED IMAGE PROCESSING 5586 03:52:57,360 --> 03:52:58,200 MODELS? 5587 03:52:58,200 --> 03:53:01,800 >>THEY NEED TO BE REPEATABLE, 5588 03:53:01,800 --> 03:53:05,000 FIRST OF ALL. 5589 03:53:05,000 --> 03:53:08,600 AND THEN THERE ARE MATRIX FOR 5590 03:53:08,600 --> 03:53:10,480 ACCURACY, BY THE IMAGING 5591 03:53:10,480 --> 03:53:14,240 PROCESSING BOOK, BOTH FOR 5592 03:53:14,240 --> 03:53:15,880 REGISTRATION, SEGMENTATION, 5593 03:53:15,880 --> 03:53:22,680 OVERLAP BETWEEN GROUND TROOP 5594 03:53:22,680 --> 03:53:24,400 SEGMENTATION AND AUTOMATIC 5595 03:53:24,400 --> 03:53:25,080 SEGMENTATION, AND FOR 5596 03:53:25,080 --> 03:53:34,480 REGISTRATION, YOU NEED TO BE 5597 03:53:34,480 --> 03:53:40,040 ABLE TO IDENTIFY. 5598 03:53:40,040 --> 03:53:41,600 FOR CERTAIN APPLICATION, 5599 03:53:41,600 --> 03:53:43,680 MILLIMETER ERROR IN REGISTRATION 5600 03:53:43,680 --> 03:53:44,800 IS OKAY, FOR OTHER APPLICATION 5601 03:53:44,800 --> 03:53:45,640 IT'S NOT OKAY. 5602 03:53:45,640 --> 03:53:49,400 IT'S WAY TOO MUCH. 5603 03:53:49,400 --> 03:53:51,880 SIMILARLY FOR SEGMENTATION YOU 5604 03:53:51,880 --> 03:53:55,960 HAVE 95 SCORE FOR BONE 5605 03:53:55,960 --> 03:53:57,360 SEGMENTATION SEND YOU BACK TO 5606 03:53:57,360 --> 03:53:59,120 THE BOARD AND UNDERSTAND WHAT 5607 03:53:59,120 --> 03:54:03,440 YOU DID WRONG AND IF YOU ADD THE 5608 03:54:03,440 --> 03:54:09,320 SAME FOR CARTILAGE OF THE HIP, 5609 03:54:09,320 --> 03:54:14,320 SO THE FINAL GOAL WOULD BE TO GO 5610 03:54:14,320 --> 03:54:16,600 FAR AS EXTRACTING BIOMARKER OF 5611 03:54:16,600 --> 03:54:21,640 INTEREST AND THAT IS THE GOLD 5612 03:54:21,640 --> 03:54:21,920 STANDARD. 5613 03:54:21,920 --> 03:54:25,040 YOUR PROCESSING DOESN'T MATTER 5614 03:54:25,040 --> 03:54:26,560 THE DIFFERENCE BUT WHAT ARE YOU 5615 03:54:26,560 --> 03:54:26,960 TRYING TO MEASURE? 5616 03:54:26,960 --> 03:54:30,080 ARE YOU TRYING TO MEASURE THE 5617 03:54:30,080 --> 03:54:31,080 CURRENT THICKNESS, HOW RELIABLE 5618 03:54:31,080 --> 03:54:32,600 ARE YOU IN DOING THAT? 5619 03:54:32,600 --> 03:54:35,200 OR YOU ARE TRYING TO MEASURE THE 5620 03:54:35,200 --> 03:54:37,160 POSITION OF THE JOINT AND 5621 03:54:37,160 --> 03:54:38,960 DYNAMIC SCAN, HOW GOOD ARE YOU 5622 03:54:38,960 --> 03:54:40,160 IN DOING THAT? 5623 03:54:40,160 --> 03:54:41,920 THAT EXACT TASK. 5624 03:54:41,920 --> 03:54:44,160 I THINK THE MATRIX ALWAYS NEED 5625 03:54:44,160 --> 03:54:48,120 TO BE RELATED TO THE DOWNSTREAM 5626 03:54:48,120 --> 03:54:50,760 TASK, AND IT'S ONLY THE 5627 03:54:50,760 --> 03:54:54,480 PRECISION ON THE DOWNSTREAM TASK 5628 03:54:54,480 --> 03:54:56,200 AND THE MINIMUM DETECTABLE 5629 03:54:56,200 --> 03:55:01,440 DIFFERENCE CLINICALLY ON THE 5630 03:55:01,440 --> 03:55:04,280 DOWNSTREAM TASK BIOMARKER THAT 5631 03:55:04,280 --> 03:55:07,480 THE MARKER THAT SET RULES ON HOW 5632 03:55:07,480 --> 03:55:09,880 PRECISE THE WHOLE PIPELINE NEED 5633 03:55:09,880 --> 03:55:10,920 TO BE. 5634 03:55:10,920 --> 03:55:13,000 >>ONE ADDITIONAL COMPONENT TOO, 5635 03:55:13,000 --> 03:55:14,840 THERE ARE ESTABLISHED METRICS 5636 03:55:14,840 --> 03:55:18,160 FOR HOW WELL YOUR SEGMENTATION 5637 03:55:18,160 --> 03:55:19,800 AND THINGS GO BUT HOW IT IMPACTS 5638 03:55:19,800 --> 03:55:22,520 WHAT YOU'RE TRYING TO DO IS 5639 03:55:22,520 --> 03:55:23,000 CRUCIAL. 5640 03:55:23,000 --> 03:55:29,200 IN OUR CASE FOR OUR DYNAMIC 5641 03:55:29,200 --> 03:55:30,920 WRIST IMAGING HAD A LOT TO DO. 5642 03:55:30,920 --> 03:55:36,840 IF YOU DIDN'T HAVE COVERAGE OF 5643 03:55:36,840 --> 03:55:38,600 YOUR CARPAL BONES NOT ABLE TO 5644 03:55:38,600 --> 03:55:40,320 TRACK BACK TO STATIC REFERENCE. 5645 03:55:40,320 --> 03:55:44,280 SO WE IN OUR FIRST PAPER ON THIS 5646 03:55:44,280 --> 03:55:46,480 IN PLOS ONE DID A MONTE CARLO 5647 03:55:46,480 --> 03:55:47,360 ANALYSIS TO OPTIMIZE OUR 5648 03:55:47,360 --> 03:55:49,960 ACQUISITION, TO DO THE BEST WE 5649 03:55:49,960 --> 03:55:54,000 POSSIBLY COULD IN ORDER TO 5650 03:55:54,000 --> 03:55:55,000 COMPUTATIONALLY FIGURE OUT WHAT 5651 03:55:55,000 --> 03:55:59,480 WE COULD DO IN TERMS OF FINAL 5652 03:55:59,480 --> 03:56:00,360 ACCURACY TRACKING DEGREES OF 5653 03:56:00,360 --> 03:56:02,920 FREEDOM OF THE BONES BASED ON MR 5654 03:56:02,920 --> 03:56:08,120 AC 5655 03:56:08,120 --> 03:56:08,280 AX. 5656 03:56:08,280 --> 03:56:10,200 WE WEREN'T LOOK AT THE ICP, WE 5657 03:56:10,200 --> 03:56:12,720 WERE LOOKING AT HOW WELL WE 5658 03:56:12,720 --> 03:56:15,760 COULD ACTUALLY TRACK THE BONES 5659 03:56:15,760 --> 03:56:18,320 AGAINST AN IN SILICO GOLD 5660 03:56:18,320 --> 03:56:19,160 STANDARD. 5661 03:56:19,160 --> 03:56:21,160 SO THERE ARE COMPUTATIONAL WAYS 5662 03:56:21,160 --> 03:56:22,040 TO DO IT. 5663 03:56:22,040 --> 03:56:23,640 TO US, THAT SEEMED LIKE A MORE 5664 03:56:23,640 --> 03:56:26,280 SENSIBLE WAY THAN TO MAKE SOME 5665 03:56:26,280 --> 03:56:27,880 SORT OF CONTRIVED PHANTOM, YOU 5666 03:56:27,880 --> 03:56:29,680 KNOW, AND ACTUALLY MOVE IT 5667 03:56:29,680 --> 03:56:31,640 AROUND AND TRACK THEM BECAUSE 5668 03:56:31,640 --> 03:56:33,680 THAT'S NOT THE REAL WORLD. 5669 03:56:33,680 --> 03:56:34,680 THE ACTUAL IMAGE CONTRAST AND 5670 03:56:34,680 --> 03:56:36,680 THINGS WE GET OUT OF REAL 5671 03:56:36,680 --> 03:56:38,480 IMAGING DATA IS DIFFERENT THAN 5672 03:56:38,480 --> 03:56:41,520 WHAT WE COULD GET IN PHANTOM 5673 03:56:41,520 --> 03:56:43,800 EXPERIMENT, I THINK 5674 03:56:43,800 --> 03:56:44,840 COMPUTATIONAL VALIDATION 5675 03:56:44,840 --> 03:56:45,920 APPROACHES USING REAL DATA IS A 5676 03:56:45,920 --> 03:56:46,880 GOOD WAY TO GO. 5677 03:56:46,880 --> 03:56:49,600 ONE FINAL COMMENT FOR ANY OF 5678 03:56:49,600 --> 03:56:50,280 THESE THINGS THAT TRANSLATE, AT 5679 03:56:50,280 --> 03:56:52,120 THE END OF THE DAY THE FDA IS 5680 03:56:52,120 --> 03:56:54,080 GOING TO BE ASKING FOR DESIGN 5681 03:56:54,080 --> 03:56:55,600 CONTROLS ON HOW YOU'RE DOING 5682 03:56:55,600 --> 03:56:55,920 EVERYTHING. 5683 03:56:55,920 --> 03:56:58,560 THEY ARE GOING TO BE LOOKING AT 5684 03:56:58,560 --> 03:56:59,680 APPROACHES AND WHERE APPROPRIATE 5685 03:56:59,680 --> 03:57:03,280 YOU'LL HAVE TO HAVE APPROPRIATE 5686 03:57:03,280 --> 03:57:04,400 VALIDATION STRATEGIES TO SHOW 5687 03:57:04,400 --> 03:57:05,840 THINGS ARE WORKING. 5688 03:57:05,840 --> 03:57:08,800 NOW AGAIN YOU CAN GO TO THE 5689 03:57:08,800 --> 03:57:09,920 ENDPOINTS AND VALIDATE THERE, 5690 03:57:09,920 --> 03:57:11,400 BUT A LOT OF TIMES THE DESIGN 5691 03:57:11,400 --> 03:57:13,120 CONTROLS ARE ALSO GOING TO HAVE 5692 03:57:13,120 --> 03:57:16,880 YOU PUTTING SOME OF THE 5693 03:57:16,880 --> 03:57:18,080 INCREMENTAL COMPONENTS WITHIN 5694 03:57:18,080 --> 03:57:19,320 YOUR ALGORITHM INTO THOSE 5695 03:57:19,320 --> 03:57:22,120 VALIDATION STRATEGIES AS WELL. 5696 03:57:22,120 --> 03:57:22,880 5697 03:57:22,880 --> 03:57:25,760 >>IF I MAY ADD ONE COMMENT, I 5698 03:57:25,760 --> 03:57:27,920 THINK WE'RE TALKING ABOUT 5699 03:57:27,920 --> 03:57:28,920 PATIENT-SPECIFIC MODELING, BUT 5700 03:57:28,920 --> 03:57:32,200 THE COMPLEXITY OF A SYSTEM IS SO 5701 03:57:32,200 --> 03:57:34,720 LARGE THAT I AM VERY PESSIMISTIC 5702 03:57:34,720 --> 03:57:37,200 WE MIGHT BE ABLE TO DO THIS 5703 03:57:37,200 --> 03:57:40,760 ROUTINELY IN A CLINICAL SETTING, 5704 03:57:40,760 --> 03:57:42,440 YOU KNOW, THE AMOUNT OF DATA YOU 5705 03:57:42,440 --> 03:57:43,240 NEED GATHER FROM THE PATIENT TO 5706 03:57:43,240 --> 03:57:47,400 BE ABLE TO COME UP WITH A 5707 03:57:47,400 --> 03:57:50,040 PERSONALIZABLE MODEL IS TOO 5708 03:57:50,040 --> 03:57:50,280 DAUNTING. 5709 03:57:50,280 --> 03:57:52,760 WE HAVE SO MANY DIFFERENT 5710 03:57:52,760 --> 03:57:54,600 MECHANISMS THAT ARE IN PLAY. 5711 03:57:54,600 --> 03:57:56,720 IT IS NEARLY IMPOSSIBLE TO 5712 03:57:56,720 --> 03:57:59,000 COLLECT ALL THE DATA. 5713 03:57:59,000 --> 03:58:04,480 SO I'M NOT SURE HOW WE CAN COME 5714 03:58:04,480 --> 03:58:06,560 UP WITH ROBUST MULTI-SCALE YET 5715 03:58:06,560 --> 03:58:08,560 SPARSE WAYS OF MODELING THESE 5716 03:58:08,560 --> 03:58:09,760 SYSTEMS, THAT MIGHT BE 5717 03:58:09,760 --> 03:58:11,400 TRANSLATABLE. 5718 03:58:11,400 --> 03:58:16,000 >>JUST TO FOLLOW UP ON THAT, A 5719 03:58:16,000 --> 03:58:17,520 LOT OF THE MUSCULOSKELETAL 5720 03:58:17,520 --> 03:58:19,600 MODELS ARE ACTIVITY SPECIFIC, 5721 03:58:19,600 --> 03:58:20,200 RIGHT? 5722 03:58:20,200 --> 03:58:22,320 GETTING STATIC DATA OF SOMEONE 5723 03:58:22,320 --> 03:58:24,080 LYING SUPINE ISN'T THAT HELPFUL. 5724 03:58:24,080 --> 03:58:26,360 WE'VE BEEN WORKING WITH 5725 03:58:26,360 --> 03:58:27,120 VOLLEYBALL PLAYERS, THEIR 5726 03:58:27,120 --> 03:58:30,960 SHOULDER IS BACK HERE, SO THE 5727 03:58:30,960 --> 03:58:33,240 MODEL WOULD FAIL BECAUSE IT -- 5728 03:58:33,240 --> 03:58:34,680 LIKE JUST GETTING SOME OF THESE 5729 03:58:34,680 --> 03:58:38,440 POSITIONS AND LIKE WHERE MUSCLES 5730 03:58:38,440 --> 03:58:41,400 AND TENDONS ATTACH REALLY 5731 03:58:41,400 --> 03:58:43,240 HELPFUL TO THE MUSCULOSKELETAL 5732 03:58:43,240 --> 03:58:45,880 MODELS TO UNDERSTAND WHAT THEIR 5733 03:58:45,880 --> 03:58:49,480 GENERIC MODEL SHOULD BE HELPING, 5734 03:58:49,480 --> 03:58:51,880 TRYING TO DETERMINE; YEAH, ON 5735 03:58:51,880 --> 03:58:52,280 ONE LAND I AGREE. 5736 03:58:52,280 --> 03:58:54,080 ON THE OTHER HAND I WILL SAY I'M 5737 03:58:54,080 --> 03:58:56,520 REALLY EXCITED BECAUSE I THINK 5738 03:58:56,520 --> 03:58:58,920 IN THE LAST LIKE FIVE YEARS AS 5739 03:58:58,920 --> 03:59:01,000 VALENTINA POINTED OUT WE MADE 5740 03:59:01,000 --> 03:59:06,920 HUGE STRIDES ON AUTOMATED 5741 03:59:06,920 --> 03:59:07,920 SEGMENTATION. 5742 03:59:07,920 --> 03:59:08,680 IN THE MUSCULOSKELETAL WORDS 5743 03:59:08,680 --> 03:59:11,400 LARGE STRIDES ON NOT NEEDING A 5744 03:59:11,400 --> 03:59:15,800 GIGANTIC GEAT GAIT WEB. 5745 03:59:15,800 --> 03:59:16,480 I AGREE IT'S DAUNTING. 5746 03:59:16,480 --> 03:59:18,200 ON THE OTHER HAND THINGS ARE 5747 03:59:18,200 --> 03:59:20,200 MOVING FAST AND I'M EXCITED 5748 03:59:20,200 --> 03:59:22,400 ABOUT WHERE WE THE ROLE OF 5749 03:59:22,400 --> 03:59:25,400 IMAGING CAN TIE IN TO HELP 5750 03:59:25,400 --> 03:59:26,440 ENHANCE THESE MUSCULOSKELETAL 5751 03:59:26,440 --> 03:59:29,000 MODELS AND MAYBE IT'S NOT 5752 03:59:29,000 --> 03:59:30,880 SPECIFICALLY AT POINT OF CARE 5753 03:59:30,880 --> 03:59:31,120 CENTER. 5754 03:59:31,120 --> 03:59:33,320 ON THE OTHER HAND MAYBE IT IS. 5755 03:59:33,320 --> 03:59:36,080 MAYBE WE CAN SAY, LIKE, WE CAN 5756 03:59:36,080 --> 03:59:37,920 DO A WALKING TEST OR SIT TO 5757 03:59:37,920 --> 03:59:39,920 STAND TEST AND TAILOR OUR 5758 03:59:39,920 --> 03:59:41,400 ACQUISITION TOWARDS SOMETHING 5759 03:59:41,400 --> 03:59:42,880 LIKE THAT, THAT COULD ENHANCE 5760 03:59:42,880 --> 03:59:43,600 IT. 5761 03:59:43,600 --> 03:59:45,800 YEAH, LIKE A GENERAL LIKE SCAN 5762 03:59:45,800 --> 03:59:48,120 SOMEONE AND FIGURE EVERYTHING 5763 03:59:48,120 --> 03:59:48,600 OUT SEEMS COMPLETELY 5764 03:59:48,600 --> 03:59:50,400 UNATTAINABLE. 5765 03:59:50,400 --> 03:59:51,640 >>THANK YOU. 5766 03:59:51,640 --> 03:59:57,080 WE HAVE A QUESTION FROM AUDIENCE 5767 03:59:57,080 --> 03:59:59,280 FOR DR. PEDOIA, IF YOU HAVE SEEN 5768 03:59:59,280 --> 04:00:01,120 ASSOCIATIONS OF BONE MARROW 5769 04:00:01,120 --> 04:00:03,560 LESIONS WITH PAIN METER MODELS. 5770 04:00:03,560 --> 04:00:09,880 >>SO THE MODEL THAT I SHOWED 5771 04:00:09,880 --> 04:00:11,640 DOES NOT TAKE INTO CONSIDERATION 5772 04:00:11,640 --> 04:00:16,000 BONE MARROW BUT WE HAD OTHER 5773 04:00:16,000 --> 04:00:17,560 MODEL BASED ON MRI PHENOTYPE. 5774 04:00:17,560 --> 04:00:19,640 WHILE THE PHENOTYPE IS BONE WITH 5775 04:00:19,640 --> 04:00:23,600 PRESENCE OF BONE MARROW, AND 5776 04:00:23,600 --> 04:00:25,320 IT'S DEFINITELY STRONG, STRONG 5777 04:00:25,320 --> 04:00:27,840 PREDICTOR OF PAIN. 5778 04:00:27,840 --> 04:00:30,680 BUT EVEN MORE IS THE 5779 04:00:30,680 --> 04:00:33,800 INFLAMMATION PHENOTYPE. 5780 04:00:33,800 --> 04:00:37,520 SO PRESENCE OF SYNOVITIS AND 5781 04:00:37,520 --> 04:00:39,280 OTHER MARKER OF INFLAMMATION. 5782 04:00:39,280 --> 04:00:42,440 THIS IS IN EVERYTHING THAT I DID 5783 04:00:42,440 --> 04:00:46,040 IN THE OSTEOARTHRITIS INITIATIVE 5784 04:00:46,040 --> 04:00:47,800 DEFINITELY THE STRONGEST 5785 04:00:47,800 --> 04:00:50,640 PREDICTOR OF PRESENCE AND 5786 04:00:50,640 --> 04:00:51,960 PROGRESSION, PROGRESSION OF PAIN 5787 04:00:51,960 --> 04:00:55,120 AND VERY CLOSE SECOND IS THE 5788 04:00:55,120 --> 04:01:02,240 PRESENCE OF BONE MARROW, SO THE 5789 04:01:02,240 --> 04:01:03,120 MARKER OF INFLAMMATION IS -- 5790 04:01:03,120 --> 04:01:07,640 THEY NEED A PLACE IN MODELING 5791 04:01:07,640 --> 04:01:08,080 AND PAIN PROGRESSION. 5792 04:01:08,080 --> 04:01:08,800 >>THANK YOU. 5793 04:01:08,800 --> 04:01:10,880 WE'RE AT THE ASSIGNED TIME SO I 5794 04:01:10,880 --> 04:01:13,720 WOULD LIKE TO THANK EVERY 5795 04:01:13,720 --> 04:01:15,040 SPEAKER AND PANELIST FOR THE 5796 04:01:15,040 --> 04:01:17,800 DISCUSSION AND PRESENTATION. 5797 04:01:17,800 --> 04:01:20,000 I'LL PASS TO CATHERINE. 5798 04:01:20,000 --> 04:01:25,400 >>THANK YOU SO MUCH, DR. DUAN 5799 04:01:25,400 --> 04:01:27,000 AND CO-CHAIRS WHO PUT TOGETHER A 5800 04:01:27,000 --> 04:01:29,080 GREAT SET OF SPEAKERS AND 5801 04:01:29,080 --> 04:01:29,360 PANELISTS. 5802 04:01:29,360 --> 04:01:32,160 THANK YOU SO MUCH FOR YOUR 5803 04:01:32,160 --> 04:01:33,120 CONTRIBUTIONS FOR SESSION 5. 5804 04:01:33,120 --> 04:01:34,440 WITH THAT BEING SAID I'M GOING 5805 04:01:34,440 --> 04:01:36,760 TO TAKE US INTO A BREAK. 5806 04:01:36,760 --> 04:01:38,720 WE HAVE 30 MINUTES. 5807 04:01:38,720 --> 04:01:43,240 WE'RE GOING TO BE REGATHERING AT 5808 04:01:43,240 --> 04:01:44,920 3:15 PROMPTLY TO BEGIN SESSION 5809 04:01:44,920 --> 04:01:45,080 6. 5810 04:01:45,080 --> 04:01:48,520 SO PLEASE GO AHEAD AND MUTE YOUR 5811 04:01:48,520 --> 04:01:51,200 AUDIO AND YOU CAN STOP YOUR 5812 04:01:51,200 --> 04:01:54,320 VIDEO FEEDS AND WE'LL BE GOING 5813 04:01:54,320 --> 04:01:54,680 INTO BREAK. 5814 04:01:54,680 --> 04:01:58,840 >>THANK YOU FOR THE VERY 5815 04:01:58,840 --> 04:01:59,320 INFORMATIVE SESSIONS. 5816 04:01:59,320 --> 04:02:00,040 >>THANK YOU. 5817 04:02:00,040 --> 04:02:01,040 WELCOME BACK. 5818 04:02:01,040 --> 04:02:04,000 I'M PLEASED TO WELCOME YOU TO 5819 04:02:04,000 --> 04:02:09,320 SESSION 6, OUR FINAL SESSION FOR 5820 04:02:09,320 --> 04:02:09,600 TODAY. 5821 04:02:09,600 --> 04:02:13,120 I'M VERY PLEASED TO INTRODUCE 5822 04:02:13,120 --> 04:02:16,840 OUR TWO SESSION CHAIRS, CHAIR 5823 04:02:16,840 --> 04:02:20,160 AND CO-CHAIR FOR SESSION 6, DR. 5824 04:02:20,160 --> 04:02:21,560 HELENE LANGEVIN, AND DR. GAYLE 5825 04:02:21,560 --> 04:02:23,000 LESTER OF NIAMS, WHO I BELIEVE 5826 04:02:23,000 --> 04:02:25,400 IS THE DIRECTOR OF THEIR 5827 04:02:25,400 --> 04:02:27,000 DIVISION OF EXTRAMURAL RESEARCH. 5828 04:02:27,000 --> 04:02:32,000 SO WITH THAT SAID, I'M GOING TO 5829 04:02:32,000 --> 04:02:33,640 STOP MY SCREEN SHARE, HELENE AND 5830 04:02:33,640 --> 04:02:39,680 TURN THINGS OVER TO YOU TO TAKE 5831 04:02:39,680 --> 04:02:41,800 IT AWAY FOR SESSION 6. 5832 04:02:41,800 --> 04:02:42,720 >>OKAY. 5833 04:02:42,720 --> 04:02:44,160 WE'RE LITERALLY DOING THIS ON 5834 04:02:44,160 --> 04:02:45,600 THE FLY RIGHT NOW. 5835 04:02:45,600 --> 04:02:50,360 AND THESE ARE JUST SOME NOTES 5836 04:02:50,360 --> 04:02:53,680 THAT GAYLE AND I WITH THE HELP 5837 04:02:53,680 --> 04:02:56,120 OF ALEX AND WEN HAVE BEEN KIND 5838 04:02:56,120 --> 04:02:57,280 OF HUDDLING OVER DURING THE 5839 04:02:57,280 --> 04:02:57,640 BREAK. 5840 04:02:57,640 --> 04:03:00,280 AND SO THIS IS REALLY MEANT TO 5841 04:03:00,280 --> 04:03:03,040 BE A STARTING POINT FOR OUR 5842 04:03:03,040 --> 04:03:04,560 DISCUSSIONS, SO I'M GOING TO BE, 5843 04:03:04,560 --> 04:03:07,040 FIRST OF ALL, SHOWING JUST A 5844 04:03:07,040 --> 04:03:11,880 COUPLE THOUGHTS ON WHAT WERE THE 5845 04:03:11,880 --> 04:03:13,840 THINGS THAT WE HEARD LOUD AND 5846 04:03:13,840 --> 04:03:15,960 CLEAR, WHAT DID PEOPLE RESONATE, 5847 04:03:15,960 --> 04:03:17,960 WHAT ARE THEMES THAT RESONATED, 5848 04:03:17,960 --> 04:03:21,320 THERE WAS A LOT OF DISCUSSION, 5849 04:03:21,320 --> 04:03:24,040 ESPECIALLY WHEN IT ADDRESSED THE 5850 04:03:24,040 --> 04:03:25,920 THEMES OF THIS WORKSHOP OF WHOLE 5851 04:03:25,920 --> 04:03:26,240 JOINT HEALTH. 5852 04:03:26,240 --> 04:03:28,840 THEN I'M GOING TO MENTION A 5853 04:03:28,840 --> 04:03:29,760 COUPLE THINGS THAT I FELT 5854 04:03:29,760 --> 04:03:32,600 PERHAPS WE DID NOT HEAR QUITE SO 5855 04:03:32,600 --> 04:03:34,240 LOUD AND CLEAR. 5856 04:03:34,240 --> 04:03:37,280 AND WHERE WE MIGHT WANT TO THINK 5857 04:03:37,280 --> 04:03:39,160 ABOUT IS THIS REALLY A GAP THAT 5858 04:03:39,160 --> 04:03:40,680 WE KNOW SO LITTLE ABOUT THAT WE 5859 04:03:40,680 --> 04:03:42,440 DIDN'T TALK ABOUT IT OR IS THIS 5860 04:03:42,440 --> 04:03:43,720 JUST SOMETHING THAT WE COULD 5861 04:03:43,720 --> 04:03:45,480 HAVE ADDRESSED AND THAT WE HAVE 5862 04:03:45,480 --> 04:03:46,920 ACTUALLY MORE INFORMATION THAN 5863 04:03:46,920 --> 04:03:49,680 ACTUALLY CAME THROUGH. 5864 04:03:49,680 --> 04:03:55,960 SO, LET ME SHARE MY SCREEN. 5865 04:03:55,960 --> 04:03:58,560 FOR A SECOND. 5866 04:03:58,560 --> 04:03:58,960 ALL RIGHT. 5867 04:03:58,960 --> 04:04:00,080 SO, LOUD AND CLEAR. 5868 04:04:00,080 --> 04:04:02,480 CAN YOU SEE THIS? 5869 04:04:02,480 --> 04:04:04,720 >>YES, WE CAN, HELEN. 5870 04:04:04,720 --> 04:04:07,880 >>SO I THINK IT'S FAIR TO SAY 5871 04:04:07,880 --> 04:04:10,680 FIRST OF ALL I KNOW I'M NOT 5872 04:04:10,680 --> 04:04:12,800 ALONE IN BEING VERY, VERY 5873 04:04:12,800 --> 04:04:15,680 PLEASED WITH HOW THE WHOLE -- 5874 04:04:15,680 --> 04:04:17,280 THE ENTIRE WORKSHOP REALLY 5875 04:04:17,280 --> 04:04:19,040 ADDRESSED VERY, VERY NICELY THE 5876 04:04:19,040 --> 04:04:20,320 THEME OF UNDERSTANDING THE WHOLE 5877 04:04:20,320 --> 04:04:20,560 JOINT. 5878 04:04:20,560 --> 04:04:22,120 I THINK THAT PEOPLE JUST REALLY 5879 04:04:22,120 --> 04:04:23,360 GOT IT. 5880 04:04:23,360 --> 04:04:26,360 THERE WAS A LOT OF TALK, BOTH ON 5881 04:04:26,360 --> 04:04:28,720 THE MECHANISM SIDE AND ALSO ON 5882 04:04:28,720 --> 04:04:30,080 THE CLINICAL SIDE OF THE 5883 04:04:30,080 --> 04:04:31,600 IMPORTANCE OF NOT JUST LOOKING 5884 04:04:31,600 --> 04:04:33,040 AT SEPARATE PARTS OF A JOINT, 5885 04:04:33,040 --> 04:04:34,560 REALLY THINKING ABOUT THE WHOLE 5886 04:04:34,560 --> 04:04:37,000 JOINT AS WE HEARD TALK ABOUT THE 5887 04:04:37,000 --> 04:04:38,600 JOINT AS AN ORGAN, AND GOING 5888 04:04:38,600 --> 04:04:41,040 BEYOND THE JOINT EVEN. 5889 04:04:41,040 --> 04:04:43,840 YOU KNOW, INCLUDING OTHER 5890 04:04:43,840 --> 04:04:48,120 ASPECTS, YOU HEARD ABOUT THE 5891 04:04:48,120 --> 04:04:49,520 DRG, NERVOUS SYSTEM. 5892 04:04:49,520 --> 04:04:51,400 SO I'M GOING TO FIRST MENTION A 5893 04:04:51,400 --> 04:04:53,600 COUPLE THINGS WHICH WE REALLY 5894 04:04:53,600 --> 04:04:55,920 FELT RESONATED ON A MECHANISTIC 5895 04:04:55,920 --> 04:04:59,080 SIDE, THE WHOLE THEME OF 5896 04:04:59,080 --> 04:05:00,480 INTERTISSUE COMMUNICATION, VERY 5897 04:05:00,480 --> 04:05:01,800 RICH DISCUSSION, ESPECIALLY 5898 04:05:01,800 --> 04:05:07,160 ABOUT THE ROLE OF ADIPOSE TISSUE 5899 04:05:07,160 --> 04:05:11,320 AND VARIOUS TYPES OF 5900 04:05:11,320 --> 04:05:12,160 INFLAMMATORY MEDIATORS, 5901 04:05:12,160 --> 04:05:13,720 CROSS-TALK BETWEEN THE DIFFERENT 5902 04:05:13,720 --> 04:05:16,680 TISSUES WITH RESPECT TO 5903 04:05:16,680 --> 04:05:18,880 INFLAMMATION, ROLE OF BONE, VERY 5904 04:05:18,880 --> 04:05:28,480 IMPORTANT, ALSO ROLE OF 5905 04:05:28,480 --> 04:05:29,000 CELLULOSENESCENCE, NICELY 5906 04:05:29,000 --> 04:05:30,920 BROUGHT UP. 5907 04:05:30,920 --> 04:05:33,240 THERE WAS NICE DISCUSSION ABOUT 5908 04:05:33,240 --> 04:05:35,120 THE INTERFACE BETWEEN MOLECULAR 5909 04:05:35,120 --> 04:05:37,840 COMPONENTS OF THE EXTRACELLULAR 5910 04:05:37,840 --> 04:05:41,000 MATRIX AND TISSUE MECHANICS. 5911 04:05:41,000 --> 04:05:44,960 MATRIX ASPECTS OF MATRIX 5912 04:05:44,960 --> 04:05:45,920 SYNTHESIS, BREAKDOWN, MATRIX 5913 04:05:45,920 --> 04:05:48,040 FRAGMENT, NICE DISCUSSION OF OF 5914 04:05:48,040 --> 04:05:55,800 THE ROLE OF HYALURONIC ACID, 5915 04:05:55,800 --> 04:05:58,280 AGGREGATION, AS RELATES TO 5916 04:05:58,280 --> 04:06:00,280 MECHANICS OF THE TISSUES, 5917 04:06:00,280 --> 04:06:01,920 STIFFNESS, LAXITY, ADHERENCE, 5918 04:06:01,920 --> 04:06:06,640 MENTION OF THESE SORT OF 5919 04:06:06,640 --> 04:06:09,240 TISSUES, TOGETHER, MECHANICS OF 5920 04:06:09,240 --> 04:06:10,000 THE JOINT, FASCINATING 5921 04:06:10,000 --> 04:06:11,120 DISCUSSION YESTERDAY ABOUT 5922 04:06:11,120 --> 04:06:14,160 HEALTHY VERSUS UNHEALTHY LOADS 5923 04:06:14,160 --> 04:06:15,720 ON JOINTS, SPECIFICALLY SI JOINT 5924 04:06:15,720 --> 04:06:23,680 DISCUSSED, VERY INTERESTING HOW 5925 04:06:23,680 --> 04:06:25,240 LITTLE WE KNOW, NICELY 5926 04:06:25,240 --> 04:06:28,480 DISCUSSED, ALSO IMPORTANCE OF IN 5927 04:06:28,480 --> 04:06:29,600 VIVO DYNAMIC MEASUREMENT 5928 04:06:29,600 --> 04:06:30,840 METHODS, NOT JUST STATICS, 5929 04:06:30,840 --> 04:06:33,560 BROUGHT UP A LOT TODAY. 5930 04:06:33,560 --> 04:06:36,320 AND NICE DISCUSSION ALSO OF 5931 04:06:36,320 --> 04:06:39,240 INTEGRATION OF MOLECULAR AND 5932 04:06:39,240 --> 04:06:41,320 STRUCTURAL IMAGING, A WAY TO 5933 04:06:41,320 --> 04:06:44,080 BRING -- A BRIEF MENTION, BUT 5934 04:06:44,080 --> 04:06:52,000 HOW TO BRING THE MOLECULAR 5935 04:06:52,000 --> 04:06:54,560 ASPECTS OF JOINT PATHOLOGY AND 5936 04:06:54,560 --> 04:06:56,760 HEALTH ALSO INTO THE STRUCTURE 5937 04:06:56,760 --> 04:07:00,000 USING COMBINATIONS OF SAY, FOR 5938 04:07:00,000 --> 04:07:00,640 EXAMPLE, PET-CT. 5939 04:07:00,640 --> 04:07:02,880 AND THEN YESTERDAY WE TALKED 5940 04:07:02,880 --> 04:07:05,160 ABOUT THE CHALLENGE OF 5941 04:07:05,160 --> 04:07:07,360 INTEGRATING VARIOUS -- A LOT OF 5942 04:07:07,360 --> 04:07:08,760 TYPES OF DATA, AND HOW IMPORTANT 5943 04:07:08,760 --> 04:07:12,440 THAT IS TO DO THIS AT THE OUTSET 5944 04:07:12,440 --> 04:07:13,720 OF RESEARCH, WITH THAT IN MIND. 5945 04:07:13,720 --> 04:07:17,800 AND OF COURSE NOW WE'RE ALL VERY 5946 04:07:17,800 --> 04:07:20,400 WELL AWARE, THIS WHOLE AREA OF 5947 04:07:20,400 --> 04:07:21,960 PUSH ON UNDERSTANDING WHAT TO DO 5948 04:07:21,960 --> 04:07:28,840 WITH THE DATA, AND USING 5949 04:07:28,840 --> 04:07:30,200 ADVANCED COMPUTATIONAL METHODS 5950 04:07:30,200 --> 04:07:31,480 INCLUDING MACHINE LEARNING, ET 5951 04:07:31,480 --> 04:07:32,120 CETERA. 5952 04:07:32,120 --> 04:07:33,440 SO WE ALL UNDERSTAND 5953 04:07:33,440 --> 04:07:34,240 INCREASINGLY HOW IMPORTANT THAT 5954 04:07:34,240 --> 04:07:38,280 IS TO THINK ABOUT THAT FROM THE 5955 04:07:38,280 --> 04:07:38,480 START. 5956 04:07:38,480 --> 04:07:41,440 NOW LET'S MOVE TO THE CLINICAL 5957 04:07:41,440 --> 04:07:42,320 SIDE. 5958 04:07:42,320 --> 04:07:47,080 AGAIN, I THINK THAT THE WHOLE 5959 04:07:47,080 --> 04:07:50,400 PERSON APPROACH WAS VERY CLEAR 5960 04:07:50,400 --> 04:07:51,520 THAT THE BIOPSYCHOSOCIAL 5961 04:07:51,520 --> 04:07:53,560 APPROACH THAT'S BEEN REALLY KIND 5962 04:07:53,560 --> 04:07:56,000 OF VERY WELL ESTABLISHED, AND 5963 04:07:56,000 --> 04:08:00,200 THE USE, THE IMPORTANCE OF USING 5964 04:08:00,200 --> 04:08:02,280 MULTI-MODAL THERAPIES, IF YOU 5965 04:08:02,280 --> 04:08:07,800 WANT TO ADDRESS THE PLURALITY OF 5966 04:08:07,800 --> 04:08:10,600 ASPECTS, ALL THE ASPECTS THAT 5967 04:08:10,600 --> 04:08:14,080 CONSTITUTE A HEALTHY OR NOT SO 5968 04:08:14,080 --> 04:08:15,720 HEALTHY JOINT, THERE WAS A VERY, 5969 04:08:15,720 --> 04:08:18,280 VERY NICE DISCUSSION OF THE 5970 04:08:18,280 --> 04:08:19,720 INTERPLAY OF DIET AND EXERCISE, 5971 04:08:19,720 --> 04:08:23,960 AS WELL AS PASSIVE AND ACTIVE 5972 04:08:23,960 --> 04:08:25,960 MECHANICAL THERAPIES. 5973 04:08:25,960 --> 04:08:28,560 NOW, I WAS VERY HAPPY ALSO TO 5974 04:08:28,560 --> 04:08:34,800 SEE THERE WAS SOME MENTION THAT 5975 04:08:34,800 --> 04:08:35,680 BOTH ANALGESIA AND RESTORATION 5976 04:08:35,680 --> 04:08:40,160 OF JOINT HEALTH GO HAND IN HAND, 5977 04:08:40,160 --> 04:08:41,680 TRANSCUTANEOUS NERVE STIMULATION 5978 04:08:41,680 --> 04:08:45,720 TO REDUCE PAIN DURING MOTION CAN 5979 04:08:45,720 --> 04:08:47,680 ENCOURAGE PEOPLE TO EXERCISE AND 5980 04:08:47,680 --> 04:08:51,640 MOVE MORE IS VERY IMPORTANT. 5981 04:08:51,640 --> 04:08:53,520 AND THAT WAS A REALLY NICE 5982 04:08:53,520 --> 04:08:57,000 EXAMPLE OF THAT. 5983 04:08:57,000 --> 04:08:57,880 SO THAT ENHANCED MOVEMENT WOULD 5984 04:08:57,880 --> 04:08:58,960 THEN BE BENEFICIAL NOT JUST FOR 5985 04:08:58,960 --> 04:09:06,080 THE JOINT BUT FOR THE WHOLE 5986 04:09:06,080 --> 04:09:06,320 PERSON. 5987 04:09:06,320 --> 04:09:08,480 THERE WAS A LOT OF DISCUSSION ON 5988 04:09:08,480 --> 04:09:11,640 CHALLENGES OF IMPLEMENTS WHAT WE 5989 04:09:11,640 --> 04:09:13,320 KNOW, THE SHOCKING STATEMENT 5990 04:09:13,320 --> 04:09:15,000 THAT ONLY 15% OF PATIENTS ARE 5991 04:09:15,000 --> 04:09:16,400 REFERRED TO PHYSICAL THERAPY 5992 04:09:16,400 --> 04:09:17,160 BEFORE JOINT REPLACEMENT 5993 04:09:17,160 --> 04:09:17,400 SURGERY. 5994 04:09:17,400 --> 04:09:19,760 THIS IS SOMETHING THAT NEEDS TO 5995 04:09:19,760 --> 04:09:23,040 CHANGE, CLEARLY THIS IS JUST 5996 04:09:23,040 --> 04:09:24,280 NOT -- WE'RE NOT OPTIMALLY 5997 04:09:24,280 --> 04:09:26,800 UTILIZING OUR KNOWLEDGE IF THIS 5998 04:09:26,800 --> 04:09:29,880 IS WHAT'S CONTINUING TO HAPPEN. 5999 04:09:29,880 --> 04:09:31,600 THERE WAS SOME DISCUSSION ABOUT 6000 04:09:31,600 --> 04:09:34,280 THE IMPORTANCE OF EVALUATING THE 6001 04:09:34,280 --> 04:09:36,720 WHOLE JOINT IN CLINICAL TRIALS, 6002 04:09:36,720 --> 04:09:38,640 MAYBE THAT'S WHY WE'RE NOT 6003 04:09:38,640 --> 04:09:40,200 REALLY GETTING THE RESULTS THAT 6004 04:09:40,200 --> 04:09:41,600 SOME TREATMENTS LOOKED AT THAT 6005 04:09:41,600 --> 04:09:45,840 ARE NOT WORKING BUT WE'RE ONLY 6006 04:09:45,840 --> 04:09:47,840 EVALUATING A LIMITED ASPECT OF 6007 04:09:47,840 --> 04:09:49,920 THE JOINT, MAYBE WE'RE ONLY JUST 6008 04:09:49,920 --> 04:09:52,080 LOOKING AT PAIN, AND WE'RE NOT 6009 04:09:52,080 --> 04:09:53,280 LOOKING AT FUNCTION. 6010 04:09:53,280 --> 04:09:57,800 WE'LL GET AT THAT LATER. 6011 04:09:57,800 --> 04:10:00,760 AND THEN THERE WAS AN 6012 04:10:00,760 --> 04:10:05,000 INTERESTING DISCUSSION ABOUT 6013 04:10:05,000 --> 04:10:13,600 USING MULTI-SCALE MODELING, 6014 04:10:13,600 --> 04:10:14,560 WHETHER THAT'S FEASIBLE FOR 6015 04:10:14,560 --> 04:10:15,640 PATIENT CARE. 6016 04:10:15,640 --> 04:10:19,000 WHAT DID WE HEAR NOT SO CLEARLY? 6017 04:10:19,000 --> 04:10:20,680 I FEEL LIKE THIS IS A WORKSHOP 6018 04:10:20,680 --> 04:10:22,680 NOT ABOUT JOINT PAIN, IT'S A 6019 04:10:22,680 --> 04:10:24,080 WORKSHOP ABOUT WHOLE JOINT 6020 04:10:24,080 --> 04:10:24,760 HEALTH. 6021 04:10:24,760 --> 04:10:28,920 WE HEARD A LOT ABOUT PAIN. 6022 04:10:28,920 --> 04:10:29,440 NOT SURPRISING. 6023 04:10:29,440 --> 04:10:31,400 IT IS IT'S MORE CHALLENGING TO 6024 04:10:31,400 --> 04:10:34,280 UNDERSTAND JOINT HEALTH THAN IT 6025 04:10:34,280 --> 04:10:36,640 IS TO STUDY PAIN. 6026 04:10:36,640 --> 04:10:38,760 BUT WE REALLY NEED TO BE SET UP, 6027 04:10:38,760 --> 04:10:40,720 TO DO MORE RESEARCH ON FUNCTION 6028 04:10:40,720 --> 04:10:43,120 AND OTHER ASPECTS OF JOINT 6029 04:10:43,120 --> 04:10:46,440 HEALTH, SOME WERE MENTIONED, 6030 04:10:46,440 --> 04:10:47,440 MOBILITY, PROPRIOCEPTION, 6031 04:10:47,440 --> 04:10:48,080 COORDINATION OF MOVEMENT, THESE 6032 04:10:48,080 --> 04:10:51,000 ARE ALL THINGS THAT ARE VERY 6033 04:10:51,000 --> 04:10:51,840 IMPORTANT THAT INVOLVE JOINTS, 6034 04:10:51,840 --> 04:10:54,840 AND THERE WAS EVEN A LITTLE BIT 6035 04:10:54,840 --> 04:10:59,200 OF TALK ABOUT POSTURE, NOT MUCH. 6036 04:10:59,200 --> 04:11:02,920 WE NEED TO -- SO CAN WE DEVELOP 6037 04:11:02,920 --> 04:11:04,000 PERSONALIZED SIGNATURES, FOR 6038 04:11:04,000 --> 04:11:06,040 EXAMPLE, OF JOINT HEALTH, NOT 6039 04:11:06,040 --> 04:11:08,720 JUST PAIN, THAT CAN BE FOLLOWED 6040 04:11:08,720 --> 04:11:10,880 OVER TIME WITHIN EACH INDIVIDUAL 6041 04:11:10,880 --> 04:11:12,200 MOVING EITHER TOWARD HEALTH OR 6042 04:11:12,200 --> 04:11:13,120 AWAY FROM HEALTH. 6043 04:11:13,120 --> 04:11:15,480 AND THAT'S THE NICE THING ABOUT 6044 04:11:15,480 --> 04:11:16,480 DOING LONGITUDINAL MEASUREMENT, 6045 04:11:16,480 --> 04:11:19,000 BECAUSE NOW YOU'RE DOING 6046 04:11:19,000 --> 04:11:21,040 MEASUREMENTS WITHIN A PERSON. 6047 04:11:21,040 --> 04:11:24,080 AND SO IT MIGHT BE -- IT MIGHT 6048 04:11:24,080 --> 04:11:26,840 BE FEASIBLE SOMETIME IN THE 6049 04:11:26,840 --> 04:11:29,960 FUTURE TO FOLLOW SOMEBODY. 6050 04:11:29,960 --> 04:11:33,000 THERE WAS NICE DISCUSSION ABOUT 6051 04:11:33,000 --> 04:11:33,720 ADAPTIVE VERSUS MALADAPTIVE 6052 04:11:33,720 --> 04:11:35,080 CHANGES, IF YOU WERE ABLE TO 6053 04:11:35,080 --> 04:11:37,120 FOLLOW SOMEBODY OVER TIME USING 6054 04:11:37,120 --> 04:11:38,760 A SET OF MEASUREMENTS, AND BE 6055 04:11:38,760 --> 04:11:41,160 ABLE TO DETECT WHETHER THIS 6056 04:11:41,160 --> 04:11:43,160 PERSON IS ADAPTING IN A GOOD OR 6057 04:11:43,160 --> 04:11:48,600 NOT SO GOOD WAY, AND GUIDE THE 6058 04:11:48,600 --> 04:11:49,960 PERSON'S MULTI-MODAL THERAPY, 6059 04:11:49,960 --> 04:11:50,240 RIGHT? 6060 04:11:50,240 --> 04:11:53,880 ACCORDING TO HOW WELL THEY 6061 04:11:53,880 --> 04:11:55,760 ARE -- HOW WELL THESE 6062 04:11:55,760 --> 04:11:57,720 MEASUREMENTS ARE, WHAT THE 6063 04:11:57,720 --> 04:12:00,200 MEASUREMENTS ARE TELLING US. 6064 04:12:00,200 --> 04:12:01,760 WHICH CAN BE I THINK THIS IS 6065 04:12:01,760 --> 04:12:02,760 SOMETHING WE'RE ALL THINKING 6066 04:12:02,760 --> 04:12:09,400 ABOUT IN TERMS OF 6067 04:12:09,400 --> 04:12:09,920 SUBJECT-SPECIFIC GUIDED 6068 04:12:09,920 --> 04:12:10,240 TREATMENT. 6069 04:12:10,240 --> 04:12:12,160 NOW, THIS IS ANOTHER ASPECT 6070 04:12:12,160 --> 04:12:15,000 WHICH I THINK WE DID NOT TOUCH 6071 04:12:15,000 --> 04:12:16,880 VERY MUCH ON, IS PREVENTION. 6072 04:12:16,880 --> 04:12:21,240 THERE WAS A LITTLE BIT OF 6073 04:12:21,240 --> 04:12:23,160 MENTION OF PREVENTION, MOST OF 6074 04:12:23,160 --> 04:12:26,800 THE DISCUSSION WAS FOCUSED ON 6075 04:12:26,800 --> 04:12:28,920 PATHOGENESIS AND TREATMENT OF 6076 04:12:28,920 --> 04:12:29,440 ESTABLISHED DISEASE. 6077 04:12:29,440 --> 04:12:31,880 THERE WAS A LITTLE BIT OF 6078 04:12:31,880 --> 04:12:32,960 DISCUSSION ON QUANTITATIVE MRI 6079 04:12:32,960 --> 04:12:38,480 FOR DETECTION OF EARLY AND 6080 04:12:38,480 --> 04:12:39,760 REVERSIBLE CARTILAGE LESION, ONE 6081 04:12:39,760 --> 04:12:42,280 TRIAL OF DIET AND EXERCISE FOR 6082 04:12:42,280 --> 04:12:43,160 O.A. PREVENTION, SOMETHING WE 6083 04:12:43,160 --> 04:12:47,120 NEED A LOT MORE OF. 6084 04:12:47,120 --> 04:12:51,720 ESPECIALLY IF WE THINK THAT BY 6085 04:12:51,720 --> 04:12:53,240 DEVELOPING MORE SOPHISTICATED 6086 04:12:53,240 --> 04:12:55,640 DIAGNOSTIC TECHNIQUES TO FOCUS 6087 04:12:55,640 --> 04:12:59,800 ON VERY EARLY CHANGES, WE MAY BE 6088 04:12:59,800 --> 04:13:01,160 ABLE TO DETECT ABNORMALITIES, 6089 04:13:01,160 --> 04:13:05,040 YOU KNOW, WHILE WE STILL CAN 6090 04:13:05,040 --> 04:13:09,480 REVERSE THEM USING, YOU KNOW, A 6091 04:13:09,480 --> 04:13:11,640 VARIETY OF DIFFERENT 6092 04:13:11,640 --> 04:13:13,280 PHARMACOLOGICAL OR 6093 04:13:13,280 --> 04:13:15,240 NON-PHARMACOLOGICAL TREATMENTS 6094 04:13:15,240 --> 04:13:17,760 TO RESTORE THE FUNCTION. 6095 04:13:17,760 --> 04:13:21,120 I WANT TO ALSO POINT OUT THAT 6096 04:13:21,120 --> 04:13:25,400 SOFT TISSUE IMAGING IS 6097 04:13:25,400 --> 04:13:27,600 DEFINITELY STILL LAGGING BEHIND. 6098 04:13:27,600 --> 04:13:29,920 YOU KNOW, WE'RE CLEARLY STILL 6099 04:13:29,920 --> 04:13:32,320 HAVE A LOT MORE EXPERIENCE IN 6100 04:13:32,320 --> 04:13:36,160 UNDERSTANDING AND DEVELOPING 6101 04:13:36,160 --> 04:13:38,040 TECHNIQUES AND INTERPRETING 6102 04:13:38,040 --> 04:13:39,640 IMAGING OF HARD TISSUE, 6103 04:13:39,640 --> 04:13:40,440 CARTILAGE, BONE, NOT SO MUCH 6104 04:13:40,440 --> 04:13:41,640 SOFT TISSUES. 6105 04:13:41,640 --> 04:13:44,280 SO WHEN WE'RE MAKING MODELS OF 6106 04:13:44,280 --> 04:13:46,120 WHOLE JOINTS, WE GOT TO MAKE 6107 04:13:46,120 --> 04:13:47,440 SURE THE ENTIRE JOINT IS IN 6108 04:13:47,440 --> 04:13:47,680 THERE. 6109 04:13:47,680 --> 04:13:50,840 IF PART OF WHAT WE'RE DOING IS 6110 04:13:50,840 --> 04:13:53,120 IMAGING, IF WE'RE NOT DETECTING, 6111 04:13:53,120 --> 04:13:55,320 FOR EXAMPLE, THE SUBTLE 6112 04:13:55,320 --> 04:13:56,960 DIFFERENCES BETWEEN JOINT 6113 04:13:56,960 --> 04:13:58,560 CAPSULE AND THE FASCIA THAT ARE 6114 04:13:58,560 --> 04:14:02,400 INVEST THE AS DR. STEEKEL WAS 6115 04:14:02,400 --> 04:14:05,520 POINTING OUT IF WE DON'T HAVE 6116 04:14:05,520 --> 04:14:06,160 IMAGING METHODS TO DIFFERENTIATE 6117 04:14:06,160 --> 04:14:08,240 WE'RE NOT GOING TO BE ABLE TO 6118 04:14:08,240 --> 04:14:10,040 ASSIGN THE CORRECT MEASUREMENT 6119 04:14:10,040 --> 04:14:11,320 AND ESPECIALLY LOOKING AT 6120 04:14:11,320 --> 04:14:12,440 INNERVATION, ALL THESE NICE 6121 04:14:12,440 --> 04:14:13,520 STUDIES OF WHOLE JOINT 6122 04:14:13,520 --> 04:14:15,480 INNERVATION, WE'VE GOT TO MAKE 6123 04:14:15,480 --> 04:14:16,920 SURE ALL THE TISSUES ARE 6124 04:14:16,920 --> 04:14:18,120 REPRESENTED IN THERE. 6125 04:14:18,120 --> 04:14:20,280 THERE WAS ONE COMMENT YESTERDAY 6126 04:14:20,280 --> 04:14:21,960 ABOUT UNDERSTANDING EFFECTS OF 6127 04:14:21,960 --> 04:14:26,640 EXERCISE, THERE'S THIS VERY 6128 04:14:26,640 --> 04:14:30,080 EXTENSIVE STUDIES OF MOTOR PACK 6129 04:14:30,080 --> 04:14:31,520 COMMON FUND PROJECT THAT SHOULD 6130 04:14:31,520 --> 04:14:33,760 BE LEVERAGED IN THIS AREA, 6131 04:14:33,760 --> 04:14:34,680 UNDERSTANDING EFFECT OF EXERCISE 6132 04:14:34,680 --> 04:14:37,000 ON THE WHOLE BODY BUT CERTAINLY 6133 04:14:37,000 --> 04:14:38,400 WOULD APPLY TO JOINTS. 6134 04:14:38,400 --> 04:14:41,160 AND THEN I ALSO ALREADY 6135 04:14:41,160 --> 04:14:42,560 MENTIONED ADAPTIVE AND 6136 04:14:42,560 --> 04:14:43,840 MALADAPTIVE PHENOTYPIC 6137 04:14:43,840 --> 04:14:44,160 EVOLUTIONS. 6138 04:14:44,160 --> 04:14:45,640 THESE WERE MY REMARKS. 6139 04:14:45,640 --> 04:14:48,120 I'M GOING TO STOP SHARING AND I 6140 04:14:48,120 --> 04:14:53,160 WILL LET GAYLE CHIME IN AND SEE 6141 04:14:53,160 --> 04:14:56,000 WHAT DID I MISS AND WHAT ELSE 6142 04:14:56,000 --> 04:14:57,720 SHE FOUND OR WHERE DID SHE AGREE 6143 04:14:57,720 --> 04:15:03,960 WITH ME. 6144 04:15:03,960 --> 04:15:04,920 6145 04:15:04,920 --> 04:15:06,960 >>GAYLE, DO YOU NEED US TO DO 6146 04:15:06,960 --> 04:15:08,520 ANYTHING ON YOUR BEHALF OR ARE 6147 04:15:08,520 --> 04:15:10,600 YOU READY TO SHARE YOUR SLIDES? 6148 04:15:10,600 --> 04:15:11,600 >>I'M READY. 6149 04:15:11,600 --> 04:15:15,960 I JUST COULDN'T GET MY MUTE OFF. 6150 04:15:15,960 --> 04:15:18,160 >>WE'RE SUPER QUICK ON OUR 6151 04:15:18,160 --> 04:15:18,360 ENDS. 6152 04:15:18,360 --> 04:15:20,840 >>YOU ARE. 6153 04:15:20,840 --> 04:15:23,240 6154 04:15:23,240 --> 04:15:24,480 OKAY, LET'S SEE. 6155 04:15:24,480 --> 04:15:26,640 I THOUGHT I WAS SHARING. 6156 04:15:26,640 --> 04:15:27,240 LET'S SEE. 6157 04:15:27,240 --> 04:15:29,640 SHARE. 6158 04:15:29,640 --> 04:15:32,600 6159 04:15:32,600 --> 04:15:36,440 OH, OKAY, THERE WE GO. 6160 04:15:36,440 --> 04:15:37,840 I THINK IT WORKED. 6161 04:15:37,840 --> 04:15:38,120 DID IT? 6162 04:15:38,120 --> 04:15:42,440 >>YES, JUST GO TO THE SLIDE 6163 04:15:42,440 --> 04:15:42,640 SHOW. 6164 04:15:42,640 --> 04:15:42,880 >>YES. 6165 04:15:42,880 --> 04:15:44,760 >>SLIDE SHOW MODE AND IT SHOULD 6166 04:15:44,760 --> 04:15:49,560 PICK UP. 6167 04:15:49,560 --> 04:15:49,840 THERE WE GO. 6168 04:15:49,840 --> 04:15:53,840 >>SO, I THINK HELENE DID AN 6169 04:15:53,840 --> 04:15:56,480 EXCELLENT JOB OF SUMMARIZING 6170 04:15:56,480 --> 04:15:58,880 SOME OF THE OBSERVATIONS THAT 6171 04:15:58,880 --> 04:16:00,280 I'M SURE MANY PEOPLE FELT 6172 04:16:00,280 --> 04:16:02,800 THROUGHOUT THE LAST TWO DAYS. 6173 04:16:02,800 --> 04:16:06,280 I WOULD LIKE TO SECOND HER 6174 04:16:06,280 --> 04:16:06,920 COMMENTS ABOUT HOW ABSOLUTELY 6175 04:16:06,920 --> 04:16:10,240 FABULOUS THE LAST TWO DAYS HAVE 6176 04:16:10,240 --> 04:16:11,160 BEEN. 6177 04:16:11,160 --> 04:16:13,280 THE PRESENTATIONS WERE SUCH HIGH 6178 04:16:13,280 --> 04:16:17,000 QUALITY AND SO HELPFUL FOR 6179 04:16:17,000 --> 04:16:18,120 UNDERSTANDING BETTER THE 6180 04:16:18,120 --> 04:16:19,400 PROBLEMS THAT ARE ENCOUNTERED 6181 04:16:19,400 --> 04:16:23,200 NOT ONLY BY THOSE OF US STUDYING 6182 04:16:23,200 --> 04:16:24,480 THE DISEASE OF OSTEOARTHRITIS 6183 04:16:24,480 --> 04:16:27,400 BUT ALSO BY THE PATIENTS WHO 6184 04:16:27,400 --> 04:16:32,440 HAVE THIS DISEASE, AND HOW THEY 6185 04:16:32,440 --> 04:16:35,160 ARE SUFFERING AND STRUGGLING 6186 04:16:35,160 --> 04:16:38,000 WITH THEIR ABILITY TO MANAGE THE 6187 04:16:38,000 --> 04:16:38,680 DISEASE ITSELF. 6188 04:16:38,680 --> 04:16:42,600 SO, I'VE MADE A FEW OBSERVATIONS 6189 04:16:42,600 --> 04:16:44,240 HERE IN THE LAST -- I'VE GOT 6190 04:16:44,240 --> 04:16:45,560 THREE SLIDES, I'LL WORK THROUGH 6191 04:16:45,560 --> 04:16:45,840 THEM. 6192 04:16:45,840 --> 04:16:49,400 AND THESE ARE ARE IN PART BASED 6193 04:16:49,400 --> 04:16:51,160 ON MY OBSERVATIONS. 6194 04:16:51,160 --> 04:16:52,640 AND FOR THOSE WHO AREN'T AWARE 6195 04:16:52,640 --> 04:17:00,440 I'M DIRECTOR OF I'M DIRECTOR OF 6196 04:17:00,440 --> 04:17:02,440 EXTRAMURAL RESEARCH AT NIAMS, 6197 04:17:02,440 --> 04:17:04,400 BUT PREVIOUSLY THE DIRECTOR, 6198 04:17:04,400 --> 04:17:09,200 PROGRAM DIRECTOR FOR CLINICAL 6199 04:17:09,200 --> 04:17:11,600 OSTEOARTHRITIS RESEARCH, AND 6200 04:17:11,600 --> 04:17:15,760 UNDER MY GUIDANCE WE DEVELOPED 6201 04:17:15,760 --> 04:17:18,400 ENTIRE RESEARCH COMMUNITY, THE 6202 04:17:18,400 --> 04:17:19,080 OSTEOARTHRITIS INITIATIVE, A 6203 04:17:19,080 --> 04:17:21,760 RESOURCE NOW BECAUSE IT'S NO 6204 04:17:21,760 --> 04:17:23,120 LONGER ENROLLING, WE'RE 6205 04:17:23,120 --> 04:17:26,480 FOLLOWING OUTCOME MEASURES. 6206 04:17:26,480 --> 04:17:28,160 BUT NO MORE FOLLOW-UP MEASURES 6207 04:17:28,160 --> 04:17:30,240 ON SUBJECTS OTHER THAN WHETHER 6208 04:17:30,240 --> 04:17:32,000 THEY HAD A TOTAL JOINT 6209 04:17:32,000 --> 04:17:34,680 REPLACEMENT OR NOT. 6210 04:17:34,680 --> 04:17:36,040 IT REMAINS A WONDERFUL RESOURCE 6211 04:17:36,040 --> 04:17:37,240 FOR THE COMMUNITY. 6212 04:17:37,240 --> 04:17:41,080 IT MAY LACK A LITTLE BIT OF THE 6213 04:17:41,080 --> 04:17:44,000 HOLISTIC APPROACH IN THE FIRST 6214 04:17:44,000 --> 04:17:45,400 BULLET BUT I WOULDN'T UNDERSELL 6215 04:17:45,400 --> 04:17:45,720 IT. 6216 04:17:45,720 --> 04:17:50,160 IT DOES HAVE ACTIVITY AND OTHER 6217 04:17:50,160 --> 04:17:53,200 DISEASES AND DOES DEAL WITH 6218 04:17:53,200 --> 04:17:53,840 DEPRESSION. 6219 04:17:53,840 --> 04:17:55,680 WE HAVE INDICES ON ALL THOSE 6220 04:17:55,680 --> 04:17:56,920 THINGS. 6221 04:17:56,920 --> 04:17:58,240 I THINK THE HOLISTIC APPROACH IS 6222 04:17:58,240 --> 04:18:00,520 NOT SO MUCH JUST LOOKING AT THE 6223 04:18:00,520 --> 04:18:05,040 PATIENT AS IT IS PROVIDING AS 6224 04:18:05,040 --> 04:18:07,640 HELENE WAS TALKING ABOUT VERY 6225 04:18:07,640 --> 04:18:13,040 HOLISTIC APPROACHES TO THE 6226 04:18:13,040 --> 04:18:15,440 TREATMENT AND HAVING INDIVIDUALS 6227 04:18:15,440 --> 04:18:18,480 BE FOLLOWED UP AND KIND OF 6228 04:18:18,480 --> 04:18:21,040 SUPERVISED WITH REGARD TO THE 6229 04:18:21,040 --> 04:18:25,560 MAINTAINING EXERCISE AND DIET 6230 04:18:25,560 --> 04:18:26,640 AND WEIGHT LOSS, 6231 04:18:26,640 --> 04:18:28,160 POST-INTERVENTIONS, OR JUST 6232 04:18:28,160 --> 04:18:30,120 EARLY ON IN DIAGNOSIS. 6233 04:18:30,120 --> 04:18:32,320 SO, THOSE ARE THE THINGS THAT I 6234 04:18:32,320 --> 04:18:34,280 THINK ARE REALLY HELPFUL FROM 6235 04:18:34,280 --> 04:18:37,800 THE LAST COUPLE OF DAYS' 6236 04:18:37,800 --> 04:18:39,360 DISCUSSION. 6237 04:18:39,360 --> 04:18:41,600 I THINK WE'RE MISSING DEFINITELY 6238 04:18:41,600 --> 04:18:42,120 MISSING INTERVENTIONS. 6239 04:18:42,120 --> 04:18:46,040 AND THIS IS SOMETHING I LEARNED 6240 04:18:46,040 --> 04:18:48,280 FROM THE OSTEOPOROSIS AREA, THAT 6241 04:18:48,280 --> 04:18:50,920 WHEN INTERVENTIONS BECOME 6242 04:18:50,920 --> 04:18:52,760 AVAILABLE THAT ARE EFFECTIVE IN 6243 04:18:52,760 --> 04:18:53,720 OSTEOARTHRITIS PREVENTING HIP 6244 04:18:53,720 --> 04:18:56,480 FRACTURE, THEN YOU BEGIN TO 6245 04:18:56,480 --> 04:18:58,480 UNDERSTAND BETTER WHAT THE 6246 04:18:58,480 --> 04:19:01,560 REALLY PIVOTAL POINTS ARE IN THE 6247 04:19:01,560 --> 04:19:03,400 ONSET, PROGRESSION, AND 6248 04:19:03,400 --> 04:19:05,160 MANAGEMENT OF THE DISEASE. 6249 04:19:05,160 --> 04:19:06,880 UNFORTUNATELY, WE HAVEN'T GOTTEN 6250 04:19:06,880 --> 04:19:08,880 THERE WITH O.A. 6251 04:19:08,880 --> 04:19:13,640 I THINK I WAS ENCOURAGED THAT 6252 04:19:13,640 --> 04:19:16,680 TMJ DISEASE MOVED BETTER, LOOKED 6253 04:19:16,680 --> 04:19:19,080 TO ME, THEIR ABILITY TO MANAGE 6254 04:19:19,080 --> 04:19:20,440 THAT DISORDER IN MANY PATIENTS. 6255 04:19:20,440 --> 04:19:24,520 I THINK WITH O.A. WE'RE STILL 6256 04:19:24,520 --> 04:19:28,160 VERY MUCH IN NEED OF EITHER 6257 04:19:28,160 --> 04:19:29,040 SURGICAL, MANUAL, OR 6258 04:19:29,040 --> 04:19:31,560 PHARMACEUTICAL INTERVENTIONS 6259 04:19:31,560 --> 04:19:32,120 THAT ARE HIGHLY EFFECTIVE. 6260 04:19:32,120 --> 04:19:33,560 THE OTHER THING I LEARNED IN THE 6261 04:19:33,560 --> 04:19:38,400 LAST COUPLE DAYS ARE THESE 6262 04:19:38,400 --> 04:19:38,800 TREATMENT TRIALS. 6263 04:19:38,800 --> 04:19:39,440 THANK YOU, CATHLEEN, VERY MUCH 6264 04:19:39,440 --> 04:19:40,000 FOR THAT. 6265 04:19:40,000 --> 04:19:43,400 THEY REALLY DO NEED TO BE 6266 04:19:43,400 --> 04:19:44,840 CAREFULLY DESIGNED. 6267 04:19:44,840 --> 04:19:46,240 NIAMS SUPPORTS A NUMBER OF 6268 04:19:46,240 --> 04:19:50,080 TRIALS IN O.A. AND HAS OVER THE 6269 04:19:50,080 --> 04:19:52,480 YEARS, AND CERTAINLY THE BIGGEST 6270 04:19:52,480 --> 04:19:58,360 PROBLEM IS THE SIZE AND LENGTH 6271 04:19:58,360 --> 04:19:59,120 OF FOLLOW-UP. 6272 04:19:59,120 --> 04:20:09,720 EAST -- OSTEOARTHRITIS IS A SLW 6273 04:20:14,320 --> 04:20:16,800 DISORDER, COMES ON SLOWLY AND 6274 04:20:16,800 --> 04:20:18,640 BECOMES CHRONIC. 6275 04:20:18,640 --> 04:20:19,520 REGENERATIVE MEDICINE, NON-HUMAN 6276 04:20:19,520 --> 04:20:23,120 MODELS FOR DISEASE ARE 6277 04:20:23,120 --> 04:20:25,320 RELATIVELY MIX AND SOMEWHAT 6278 04:20:25,320 --> 04:20:27,920 INADEQUATE, SEEMS LIKE A GAP, 6279 04:20:27,920 --> 04:20:30,480 SEEMS LINE AN AREA WE CAN 6280 04:20:30,480 --> 04:20:31,760 UNDERSTAND FROM THE MOUSE, SOME 6281 04:20:31,760 --> 04:20:34,800 OF THE CHANGES THAT ARE 6282 04:20:34,800 --> 04:20:36,560 OCCURRING IN THE TISSUES, BUT 6283 04:20:36,560 --> 04:20:42,200 IT'S VERY DIVERSITY DOLT T. - 6284 04:20:42,200 --> 04:20:43,280 DIFFICULT TO HAVE MECHANICAL 6285 04:20:43,280 --> 04:20:44,800 UNDERSTANDING FROM THE MODELS 6286 04:20:44,800 --> 04:20:46,320 ALTHOUGH WE ARE IMPROVING. 6287 04:20:46,320 --> 04:20:50,280 I WAS SIMULTANEOUSLY AT A 6288 04:20:50,280 --> 04:20:51,960 MUSCULOSKELETAL CONFERENCE IN 6289 04:20:51,960 --> 04:20:53,480 UTAH, AND WE'VE SEEN OVER THE 6290 04:20:53,480 --> 04:20:55,520 DAYS PRIOR TO THIS WHEN I WAS 6291 04:20:55,520 --> 04:20:57,520 ABLE TO GO TO THAT MEETING THAT 6292 04:20:57,520 --> 04:20:59,600 THERE ARE SOME MODELS THAT ARE 6293 04:20:59,600 --> 04:21:03,960 BEING DEVELOPED THAT DO MIMIC 6294 04:21:03,960 --> 04:21:05,600 SOME OF THE BIOMECHANICAL IMPACT 6295 04:21:05,600 --> 04:21:08,120 THAT THE BONES ARE SUBJECTED TO, 6296 04:21:08,120 --> 04:21:10,760 AND THAT CAUSE BONE REMODELING 6297 04:21:10,760 --> 04:21:11,960 AND CHANGES. 6298 04:21:11,960 --> 04:21:13,280 BUT THE NON-HUMAN MODELS SEEM TO 6299 04:21:13,280 --> 04:21:18,720 ME TO BE AN AREA WHERE WE COULD 6300 04:21:18,720 --> 04:21:21,320 MAYBE MAKE SOME SIGNIFICANT 6301 04:21:21,320 --> 04:21:21,960 STRIDES. 6302 04:21:21,960 --> 04:21:24,040 THE OTHER ISSUE IS REALLY MORE 6303 04:21:24,040 --> 04:21:25,440 RELATED TO CLINICAL BUT 6304 04:21:25,440 --> 04:21:29,040 CERTAINLY HAS AN IMPACT ON 6305 04:21:29,040 --> 04:21:31,200 ANIMAL MODELS, OUTCOME MEASURES, 6306 04:21:31,200 --> 04:21:33,400 OTHER THAN PAIN WHERE WE'VE GOT 6307 04:21:33,400 --> 04:21:36,320 BETTER AT ASSESSING PAIN AND 6308 04:21:36,320 --> 04:21:41,200 PAIN SENSITIVITY, BUT WE STILL 6309 04:21:41,200 --> 04:21:43,440 HAVEN'T GOT A VERY GOOD OUTCOME 6310 04:21:43,440 --> 04:21:46,680 MEASURE FOR O.A. AND CERTAINLY 6311 04:21:46,680 --> 04:21:48,920 ANYONE WHO TRIED TO DO CLINICAL 6312 04:21:48,920 --> 04:21:50,640 STUDIES WELL AWARE OF THAT, SO 6313 04:21:50,640 --> 04:21:51,400 THAT'S AN AREA THERE ARE 6314 04:21:51,400 --> 04:21:52,760 CERTAINLY GAPS. 6315 04:21:52,760 --> 04:21:54,240 AND THEN THE POINT THAT I 6316 04:21:54,240 --> 04:21:58,200 THOUGHT WAS REALLY EXCELLENT WAS 6317 04:21:58,200 --> 04:21:59,720 MADE YESTERDAY, YOU KNOW, 6318 04:21:59,720 --> 04:22:00,840 OSTEOARTHRITIS IS NOT REALLY A 6319 04:22:00,840 --> 04:22:02,200 SINGLE DISEASE. 6320 04:22:02,200 --> 04:22:05,080 IT HAS VARIATIONS IN THE 6321 04:22:05,080 --> 04:22:07,080 MANIFESTATIONS AND CAUSATIONS 6322 04:22:07,080 --> 04:22:08,680 FROM PATIENT TO PATIENT. 6323 04:22:08,680 --> 04:22:13,680 SO IT'S RELATIVELY HARD TO 6324 04:22:13,680 --> 04:22:17,040 CATEGORIZE IT VERY SUCCINCTLY AS 6325 04:22:17,040 --> 04:22:17,920 YOU CAN OTHER DISEASES. 6326 04:22:17,920 --> 04:22:19,920 ANOTHER POINT THAT I LEARNED 6327 04:22:19,920 --> 04:22:22,240 FROM THESE DISCUSSIONS AND THIS 6328 04:22:22,240 --> 04:22:26,280 GOES BACK TO ONE OF HELENE'S 6329 04:22:26,280 --> 04:22:27,760 COMMENTS RECENTLY IN THE LAST 6330 04:22:27,760 --> 04:22:33,600 PART OF HER TALK ABOUT 6331 04:22:33,600 --> 04:22:40,560 STIFFNESS, AND THE LACK OF 6332 04:22:40,560 --> 04:22:47,040 FLEXIBILITY OR LACK OF EXERCISE 6333 04:22:47,040 --> 04:22:49,640 LEAN NOT ONLY TO FURTHER JOINT 6334 04:22:49,640 --> 04:22:53,040 DEGRADATION OR ONSET OF DISEASE 6335 04:22:53,040 --> 04:22:54,120 BUT LOSS OF FUNCTION OR 6336 04:22:54,120 --> 04:22:54,760 STABILITY IN THE PATIENT. 6337 04:22:54,760 --> 04:22:59,360 SO THIS IS A VERY BIG IMPACT ON 6338 04:22:59,360 --> 04:23:02,760 LIFE AND ON YOUR ABILITY TO TAKE 6339 04:23:02,760 --> 04:23:04,840 CARE OF YOURSELF. 6340 04:23:04,840 --> 04:23:08,000 SO THE DEVELOPMENT DISABILITY IS 6341 04:23:08,000 --> 04:23:09,120 HIGHLY ASSOCIATED WITH 6342 04:23:09,120 --> 04:23:10,200 OSTEOARTHRITIS. 6343 04:23:10,200 --> 04:23:12,280 SO, IF WE CAN UNDERSTAND 6344 04:23:12,280 --> 04:23:14,920 STIFFNESS BETTER, WE COULD 6345 04:23:14,920 --> 04:23:15,920 POSSIBLY UNDERSTAND HOW TO 6346 04:23:15,920 --> 04:23:17,760 ALLEVIATE SOME OF THAT. 6347 04:23:17,760 --> 04:23:19,960 WE DO KNOW THAT EXERCISE HELPS A 6348 04:23:19,960 --> 04:23:20,320 LOT. 6349 04:23:20,320 --> 04:23:23,240 BUT I HEARD SOMEONE SAY THAT IN 6350 04:23:23,240 --> 04:23:25,200 SOME CASES EXERCISE, IF YOU'RE 6351 04:23:25,200 --> 04:23:27,280 IN THE WRONG STATE, EXERCISE CAN 6352 04:23:27,280 --> 04:23:28,280 MAKE IT WORSE. 6353 04:23:28,280 --> 04:23:31,440 SO THAT NEEDS TO BE TEASED OUT A 6354 04:23:31,440 --> 04:23:33,600 LITTLE BIT MORE. 6355 04:23:33,600 --> 04:23:38,600 I THINK THE TALK BY KELSEY 6356 04:23:38,600 --> 04:23:39,240 COLLINS WAS INFORMATIVE AND I'VE 6357 04:23:39,240 --> 04:23:45,680 SEEN HER WORK BEFORE AND FIND IT 6358 04:23:45,680 --> 04:23:48,560 QUITE FASCINATING. 6359 04:23:48,560 --> 04:23:49,160 AND TAMARA ALLISON, UNIVERSITY 6360 04:23:49,160 --> 04:23:51,280 OF CALIFORNIA, SAN FRANCISCO 6361 04:23:51,280 --> 04:23:51,840 CROSS-TALK BETWEEN CELL 6362 04:23:51,840 --> 04:23:53,360 POPULATIONS AND JOINTS, REALLY 6363 04:23:53,360 --> 04:23:56,960 HOPING THIS WOULD LEAD TO SOME 6364 04:23:56,960 --> 04:23:58,520 NEW TREATMENT TARGETS THAT MAY 6365 04:23:58,520 --> 04:24:01,240 BE HELPFUL AND MAY BE THAT WE 6366 04:24:01,240 --> 04:24:03,000 NEED THIS MULTI-MODAL TYPE OF 6367 04:24:03,000 --> 04:24:06,600 TREATMENT WHERE NOT ONLY ARE WE 6368 04:24:06,600 --> 04:24:09,000 TAKING A PHARMACEUTICAL AGENT TO 6369 04:24:09,000 --> 04:24:19,480 CONTROL THE CROSS-TALK ASPECTS 6370 04:24:20,040 --> 04:24:25,480 BUT THERE ARE ALSO AND PHYSICAL 6371 04:24:25,480 --> 04:24:27,120 THERAPY ASPECTS AS WELL. 6372 04:24:27,120 --> 04:24:31,280 NON-HUMAN MODELS OF O.A. ARE 6373 04:24:31,280 --> 04:24:32,880 LIMITED, I SAID THAT PREVIOUSLY 6374 04:24:32,880 --> 04:24:34,600 BUT WE MADE THESE SLIDES IN 6375 04:24:34,600 --> 04:24:36,320 ABOUT THREE MINUTES A LITTLE 6376 04:24:36,320 --> 04:24:37,520 WHILE AGO. 6377 04:24:37,520 --> 04:24:41,200 I FOUND TODAY'S DISCUSSION OF 6378 04:24:41,200 --> 04:24:42,560 MACHINE LEARNING AND ARTIFICIAL 6379 04:24:42,560 --> 04:24:46,640 INTELLIGENCE THROUGH THE IMAGING 6380 04:24:46,640 --> 04:24:48,440 TO BE INCREDIBLY HELPFUL AND 6381 04:24:48,440 --> 04:24:50,560 ENCOURAGING TO ME THAT WE MAY BE 6382 04:24:50,560 --> 04:24:52,640 ABLE TO REALLY LEARN A LOT FROM 6383 04:24:52,640 --> 04:24:55,120 THE LARGE DATASETS THAT WE HAVE, 6384 04:24:55,120 --> 04:24:58,400 AND SOME OF THE M.R. IMAGING 6385 04:24:58,400 --> 04:25:02,080 THAT WE'VE DONE IN THE CLINICAL 6386 04:25:02,080 --> 04:25:04,960 O.A. ARENA, BUT THEN THE FINAL 6387 04:25:04,960 --> 04:25:05,960 BULLET, HARMONIZATION OF 6388 04:25:05,960 --> 04:25:07,920 DATASETS AND INCLUSION OF COMMON 6389 04:25:07,920 --> 04:25:11,200 DATA ELEMENTS IS REALLY CRITICAL 6390 04:25:11,200 --> 04:25:14,120 FOR THAT TO BE EFFECTIVE. 6391 04:25:14,120 --> 04:25:15,960 AND SO THOSE TWO BULLETS COULD 6392 04:25:15,960 --> 04:25:17,880 NEED AN INITIATIVE TO JUST TRY 6393 04:25:17,880 --> 04:25:21,560 TO GET -- THERE ARE A NUMBER OF 6394 04:25:21,560 --> 04:25:23,640 LARGE COHORT STUDIES ON OA, TO 6395 04:25:23,640 --> 04:25:26,360 GET THEM HARMONIZED AND HAVE THE 6396 04:25:26,360 --> 04:25:27,680 OUTCOME MEASURES STANDARDIZED OR 6397 04:25:27,680 --> 04:25:29,760 AT LEAST FIGURE OUT WHAT COULD 6398 04:25:29,760 --> 04:25:33,720 BE USED FROM THESE LARGER 6399 04:25:33,720 --> 04:25:35,440 DATASETS. 6400 04:25:35,440 --> 04:25:37,640 SO I WAS HAVING STARTED REALLY 6401 04:25:37,640 --> 04:25:39,800 THINK BEEN INVOLVED IN SOME OF 6402 04:25:39,800 --> 04:25:45,480 THE EARLY DAYS OF M.R. IMAGING 6403 04:25:45,480 --> 04:25:48,360 IN O.A. WAS EXCITED TO SEE 6404 04:25:48,360 --> 04:25:50,000 PRESENTATIONS FROM THE IMAGERS 6405 04:25:50,000 --> 04:25:52,040 TODAY SO THANKS SO MUCH FOR 6406 04:25:52,040 --> 04:25:52,640 THAT. 6407 04:25:52,640 --> 04:26:00,280 LET'S GO TO MY LAST SLIDE. 6408 04:26:00,280 --> 04:26:01,360 THESE ARE QUESTIONS TO THROW OUT 6409 04:26:01,360 --> 04:26:02,080 THERE. 6410 04:26:02,080 --> 04:26:03,360 HOW CAN THE LARGER RESEARCH 6411 04:26:03,360 --> 04:26:06,000 COMMUNITY ADDRESS THESE GAPS AND 6412 04:26:06,000 --> 04:26:10,040 OPPORTUNITIES THAT HELENE AND I 6413 04:26:10,040 --> 04:26:11,680 HAVE SUMMARIZED FOR YOU, HAVE WE 6414 04:26:11,680 --> 04:26:12,560 MISSED SOMETHING? 6415 04:26:12,560 --> 04:26:16,600 DO WE NEED MORE BASIC STUDIES? 6416 04:26:16,600 --> 04:26:21,560 WE DO KNOW WE NEED MORE IMPROVED 6417 04:26:21,560 --> 04:26:23,640 CLINICAL STUDIES. 6418 04:26:23,640 --> 04:26:25,280 ARE THERE ANY EFFECTIVE -- WELL, 6419 04:26:25,280 --> 04:26:27,120 THIS WAS MY POINT BEFORE THAT 6420 04:26:27,120 --> 04:26:29,120 EFFECTIVE TREATMENTS ARE NEEDED 6421 04:26:29,120 --> 04:26:31,520 TO ENABLE THE FULL -- MORE FULL 6422 04:26:31,520 --> 04:26:33,680 UNDERSTANDING OF DISEASE, AND 6423 04:26:33,680 --> 04:26:36,520 DISEASE PROGRESSION. 6424 04:26:36,520 --> 04:26:37,640 AND CAN WE IDENTIFY SOME NEXT 6425 04:26:37,640 --> 04:26:39,080 STEPS, AND THIS IS WHAT THIS 6426 04:26:39,080 --> 04:26:43,200 SESSION IS FOR, SO I HOPE 6427 04:26:43,200 --> 04:26:44,840 EVERYONE, ONCE I'VE STOPPED 6428 04:26:44,840 --> 04:26:46,280 TALKING, WILL PROVIDE THEIR 6429 04:26:46,280 --> 04:26:47,960 INPUT ON THIS. 6430 04:26:47,960 --> 04:26:49,040 IDENTIFY SOME NEXT STEPS BASED 6431 04:26:49,040 --> 04:26:51,120 ON THE DISCUSSIONS OF THE PAST 6432 04:26:51,120 --> 04:26:54,760 TWO DAYS. 6433 04:26:54,760 --> 04:26:56,720 I'D LIKE TO THANK EVERYBODY FOR 6434 04:26:56,720 --> 04:26:59,000 THEIR ATTENTION AND OPEN IT UP, 6435 04:26:59,000 --> 04:27:05,600 SEND IT BACK TO HELENE FOR HER 6436 04:27:05,600 --> 04:27:05,880 COMMENTS. 6437 04:27:05,880 --> 04:27:10,840 >>THANK YOU, GAYLE. 6438 04:27:10,840 --> 04:27:12,920 THERE WERE SO MANY, YOU KNOW, 6439 04:27:12,920 --> 04:27:16,520 SUCH A DIFFERENT ASPECT OF HOW 6440 04:27:16,520 --> 04:27:17,560 WE INTERPRETED THE DISCUSSIONS 6441 04:27:17,560 --> 04:27:20,000 BUT THERE ARE A LOT OF VERY 6442 04:27:20,000 --> 04:27:21,440 COMMON, YOU KNOW, POINTS BETWEEN 6443 04:27:21,440 --> 04:27:26,600 WHAT GAYLE AND I HEARD. 6444 04:27:26,600 --> 04:27:27,800 SO, WHO IS GOING TO PANEL THE 6445 04:27:27,800 --> 04:27:30,520 QUESTIONS NOW? 6446 04:27:30,520 --> 04:27:32,040 6447 04:27:32,040 --> 04:27:35,440 >>WE HAVE SUBMITTED QUESTIONS, 6448 04:27:35,440 --> 04:27:38,600 CATHERINE CAN POPULATE THEM IN 6449 04:27:38,600 --> 04:27:39,480 THE CHAT. 6450 04:27:39,480 --> 04:27:42,320 ALSO SEEMS LIKE THIS IS AN 6451 04:27:42,320 --> 04:27:43,920 OPPORTUNITY IF MEMBERS, 6452 04:27:43,920 --> 04:27:45,280 PANELISTS AND SPEAKERS, WOULD 6453 04:27:45,280 --> 04:27:48,040 LIKE TO REACT TO WHAT THEY JUST 6454 04:27:48,040 --> 04:27:48,200 SAW. 6455 04:27:48,200 --> 04:27:48,760 >>ABSOLUTELY. 6456 04:27:48,760 --> 04:27:50,920 IF THERE'S SOMETHING THAT YOU 6457 04:27:50,920 --> 04:27:53,800 DISAGREE, FEEL LIKE OH MY GOD, 6458 04:27:53,800 --> 04:27:55,160 YOU FORGOT ABOUT THIS, FEEL FREE 6459 04:27:55,160 --> 04:27:59,800 POINT IT OUT. 6460 04:27:59,800 --> 04:28:04,000 >>HELENE I'M GOING TO DROP IN A 6461 04:28:04,000 --> 04:28:05,440 QUESTION THAT WAS SHARED, 6462 04:28:05,440 --> 04:28:07,040 SENDING IT TO EVERYONE IN THE 6463 04:28:07,040 --> 04:28:09,040 CHAT NOW, WHERE HE'S ASKING 6464 04:28:09,040 --> 04:28:11,880 ABOUT HOW TO RESEARCH 6465 04:28:11,880 --> 04:28:12,640 MULTI-MODAL INTERVENTIONS OF 6466 04:28:12,640 --> 04:28:14,280 MUSCULOSKELETAL MEDICINE TO 6467 04:28:14,280 --> 04:28:15,520 MIMIC HOW CLINICIANS ACTUALLY 6468 04:28:15,520 --> 04:28:18,320 TREAT PATIENTS AND HOW DO WE GET 6469 04:28:18,320 --> 04:28:19,120 AWAY FROM THE REDUCTIONIST 6470 04:28:19,120 --> 04:28:21,600 APPROACH AND GET TO A MORE 6471 04:28:21,600 --> 04:28:22,280 COMPREHENSIVE APPROACH. 6472 04:28:22,280 --> 04:28:28,600 I'VE DROPPED THAT INTO THE CHAT 6473 04:28:28,600 --> 04:28:31,920 IF YOU WANT TO KICK OFF OR TAKE 6474 04:28:31,920 --> 04:28:37,040 THINGS FROM THE FLOOR AND I'LL 6475 04:28:37,040 --> 04:28:38,240 KEEP CHATTING IN QUESTIONS. 6476 04:28:38,240 --> 04:28:41,240 >>DO YOU WANT TO ELABORATE ON 6477 04:28:41,240 --> 04:28:45,920 EXACTLY WHAT YOU MEAN HERE? 6478 04:28:45,920 --> 04:28:47,480 >>AS CLINICIANS, WE SEE THE 6479 04:28:47,480 --> 04:28:49,680 PATIENT COME IN AND THEY'VE GOT 6480 04:28:49,680 --> 04:28:51,120 A COMPLAINT, KNEE PAIN, BACK 6481 04:28:51,120 --> 04:28:53,520 PAIN, ET CETERA, AND TYPICALLY 6482 04:28:53,520 --> 04:28:56,760 WE DON'T TREAT IT WITH JUST ONE 6483 04:28:56,760 --> 04:28:56,960 THING. 6484 04:28:56,960 --> 04:28:58,080 THAT WAS SORT OF ONE OF THE 6485 04:28:58,080 --> 04:29:00,360 THINGS I WAS TRYING TO EMPHASIZE 6486 04:29:00,360 --> 04:29:02,920 WITH THE CLINICAL VIGNETTE I 6487 04:29:02,920 --> 04:29:06,400 SHARED, WE MIGHT BE TREATING 6488 04:29:06,400 --> 04:29:08,360 WITH MORPHOBIOLOGICS, MANUAL 6489 04:29:08,360 --> 04:29:09,600 THERAPY, ADDING PHYSICAL THERAPY 6490 04:29:09,600 --> 04:29:10,440 TO THAT. 6491 04:29:10,440 --> 04:29:13,400 AS I OFTEN TELL MY FELLOWS, 6492 04:29:13,400 --> 04:29:15,160 SOMEBODY THAT COMES WITH KNEE 6493 04:29:15,160 --> 04:29:17,680 PAIN, KNEE PAIN IS A RESULT OF A 6494 04:29:17,680 --> 04:29:19,360 BAD FOOT OR BAD HIP 6495 04:29:19,360 --> 04:29:20,400 BIOMECHANICS, YOU'VE LOST MOTION 6496 04:29:20,400 --> 04:29:23,840 IN ONE OR BOTH OF THOSE AREAS 6497 04:29:23,840 --> 04:29:25,040 THE KNEE GETS OVERLOADED. 6498 04:29:25,040 --> 04:29:27,120 IF YOU'RE JUST TREATING THE KNEE 6499 04:29:27,120 --> 04:29:27,880 YOU'RE ZOOMED TO FAILURE, YOU 6500 04:29:27,880 --> 04:29:30,840 HAVE TO FIND OUT BIOMECHANICAL 6501 04:29:30,840 --> 04:29:31,960 DRIVER FOR THAT PARTICULAR 6502 04:29:31,960 --> 04:29:34,880 TISSUE OR JOINT TO BE 6503 04:29:34,880 --> 04:29:35,200 OVERLOADED. 6504 04:29:35,200 --> 04:29:38,720 SO WE TYPICALLY DON'T JUST DO 6505 04:29:38,720 --> 04:29:39,400 ANTI-INFLAMMATORY MEDICINE, 6506 04:29:39,400 --> 04:29:41,320 INJECTIONS, BUT A LOT OF THE 6507 04:29:41,320 --> 04:29:46,800 TRIALS SORT OF FOCUS ON 6508 04:29:46,800 --> 04:29:51,160 INTERVENTION, DO THEY LOOK AT 6509 04:29:51,160 --> 04:29:59,520 LEG LEANING EQUITY, VARUS VALGUS 6510 04:29:59,520 --> 04:30:00,240 ISSUES, GAIT. 6511 04:30:00,240 --> 04:30:02,240 COMPREHENSIVE FUNCTIONAL BODY IS 6512 04:30:02,240 --> 04:30:03,920 KEY, CAN WE IMAGE AND FIGURE 6513 04:30:03,920 --> 04:30:04,760 THIS OUT? 6514 04:30:04,760 --> 04:30:06,960 WE HAVE A LOT OF CLINICAL TOOLS 6515 04:30:06,960 --> 04:30:08,480 RIGHT NOW THAT COULD HELP US 6516 04:30:08,480 --> 04:30:11,200 WITH THAT IN TERMS OF LOOKING AT 6517 04:30:11,200 --> 04:30:17,360 JOINT RANGE OF MOTION, 6518 04:30:17,360 --> 04:30:18,000 STRUCTURE-FUNCTION RELATIONSHIP, 6519 04:30:18,000 --> 04:30:21,960 TO FIGURE OUT WHAT'S IMPORTANT 6520 04:30:21,960 --> 04:30:22,720 FROM IMAGING PERSPECTIVE, FROM, 6521 04:30:22,720 --> 04:30:24,480 YOU KNOW, YOU'VE GOT THE 6522 04:30:24,480 --> 04:30:25,520 PATIENT, PHENOTYPE IN FRONT OF 6523 04:30:25,520 --> 04:30:28,080 YOU, BUT A LOT OF TALK ABOUT 6524 04:30:28,080 --> 04:30:30,480 OTHER TYPES OF BLOOD TESTING 6525 04:30:30,480 --> 04:30:32,680 THAT MIGHT BE DONE SO, AGAIN, 6526 04:30:32,680 --> 04:30:33,920 I'M GETTING OFF SUBJECT HERE BUT 6527 04:30:33,920 --> 04:30:38,360 JUST TRYING TO LOOK AT HOW DO WE 6528 04:30:38,360 --> 04:30:39,240 CONSTRUCT THESE APPROACHES TO 6529 04:30:39,240 --> 04:30:41,400 MIMIC WHAT CLINICIANS ARE 6530 04:30:41,400 --> 04:30:42,960 ACTUALLY DOING. 6531 04:30:42,960 --> 04:30:44,600 AND SO THAT'S HOPEFULLY, I DON'T 6532 04:30:44,600 --> 04:30:49,880 KNOW IF I CONFUSED YOU OR MAYBE 6533 04:30:49,880 --> 04:30:50,200 HOPEFULLY -- 6534 04:30:50,200 --> 04:30:55,240 >>WELL, NO, THERE IS -- AMANDA, 6535 04:30:55,240 --> 04:30:59,240 DO YOU WANT TO ELABORATE, 6536 04:30:59,240 --> 04:31:00,080 AMANDA? 6537 04:31:00,080 --> 04:31:00,640 WHERE IS AMANDA? 6538 04:31:00,640 --> 04:31:03,800 >>LOVE TO HEAR FROM HER, YEAH. 6539 04:31:03,800 --> 04:31:07,960 AMANDA, CAN YOU GET YOUR MUTE 6540 04:31:07,960 --> 04:31:08,120 OFF? 6541 04:31:08,120 --> 04:31:08,960 >>I'M TRYING. 6542 04:31:08,960 --> 04:31:10,680 THERE I AM. 6543 04:31:10,680 --> 04:31:12,360 YEAH, SO THERE ARE -- THIS WAS 6544 04:31:12,360 --> 04:31:14,320 ALLUDED TO IN AN EARLIER TALK, 6545 04:31:14,320 --> 04:31:18,200 THERE ARE ADVANCED STUDY DESIGNS 6546 04:31:18,200 --> 04:31:21,000 THAT ALLOW USE OF MULTI-MODAL 6547 04:31:21,000 --> 04:31:22,200 INTERVENTIONS THAT CAN CHANGE 6548 04:31:22,200 --> 04:31:23,520 ALONG THE WAY SO RATHER THAN 6549 04:31:23,520 --> 04:31:25,280 ASSIGNING PEOPLE AT THE VERY 6550 04:31:25,280 --> 04:31:26,840 BEGINNING OF A TRIAL AND SENDING 6551 04:31:26,840 --> 04:31:27,960 THEM DOWN AN ARM THEY ARE GOING 6552 04:31:27,960 --> 04:31:33,000 TO BE STUCK IN FOR 18 MONTHS, 6553 04:31:33,000 --> 04:31:34,160 YOU CAN CHANGE, RIGHT? 6554 04:31:34,160 --> 04:31:35,560 IF THEY DON'T RESPOND TO FIRST 6555 04:31:35,560 --> 04:31:37,120 INTERVENTION, YOU MOVE TO THE 6556 04:31:37,120 --> 04:31:39,440 SECOND OR INCREASE DOSE OF THE 6557 04:31:39,440 --> 04:31:40,120 FIRST INTERVENTION, WHATEVER IT 6558 04:31:40,120 --> 04:31:40,280 IS. 6559 04:31:40,280 --> 04:31:43,040 IT COULD BE ANY OF THOSE THINGS, 6560 04:31:43,040 --> 04:31:44,760 ADDING ON A NEW INTERVENTION. 6561 04:31:44,760 --> 04:31:49,400 AND THEY ARE ADAPTIVE OVER TIME, 6562 04:31:49,400 --> 04:31:52,000 USED IN ASTHMA AND OTHER AREAS, 6563 04:31:52,000 --> 04:31:52,720 CREEPING INTO OUR WORK. 6564 04:31:52,720 --> 04:31:56,840 ONE OF OUR COLLEAGUES AT UNC 6565 04:31:56,840 --> 04:31:59,560 USES THEM IN GERIATRICS, WEIGHT 6566 04:31:59,560 --> 04:32:01,240 LOSS, MAINTAINING FUNCTIONAL 6567 04:32:01,240 --> 04:32:01,760 MOBILITY. 6568 04:32:01,760 --> 04:32:02,640 THAT'S ONE THING. 6569 04:32:02,640 --> 04:32:03,760 ENROLLING THE RIGHT PEOPLE AT 6570 04:32:03,760 --> 04:32:04,960 THE BEGINNING MORE ADEQUATELY 6571 04:32:04,960 --> 04:32:06,080 PHENOTYPING THE WHOLE PATIENT 6572 04:32:06,080 --> 04:32:08,680 WE'VE TALKED ABOUT A FEW TIMES. 6573 04:32:08,680 --> 04:32:09,920 SO THAT YOU'RE ADJUSTING THESE 6574 04:32:09,920 --> 04:32:11,680 THINGS FOR THE RIGHT REASONS AND 6575 04:32:11,680 --> 04:32:14,200 RIGHT PEOPLE. 6576 04:32:14,200 --> 04:32:15,400 6577 04:32:15,400 --> 04:32:20,000 >>SO, ANOTHER THING TO DR. 6578 04:32:20,000 --> 04:32:21,200 BROLIN'S QUESTION, I THINK YOU 6579 04:32:21,200 --> 04:32:24,000 WERE TALKING MORE ABOUT HAVING 6580 04:32:24,000 --> 04:32:28,200 ENOUGH TIME AS A CLINICIAN TO 6581 04:32:28,200 --> 04:32:29,800 ACTUALLY EXAMINE THE PATIENT 6582 04:32:29,800 --> 04:32:32,640 THROUGH ALL THESE DIFFERENT 6583 04:32:32,640 --> 04:32:38,280 DIMENSIONS, AND THEN TO HAVE 6584 04:32:38,280 --> 04:32:40,000 ENOUGH TIME TO IMBIBE IN PART 6585 04:32:40,000 --> 04:32:43,280 WHAT NEEDS TO BE DONE, THAT'S A 6586 04:32:43,280 --> 04:32:48,000 HUGE PROBLEM FOR CLINICIANS, THE 6587 04:32:48,000 --> 04:32:51,240 THINGS WE'RE TALKING ABOUT, 6588 04:32:51,240 --> 04:32:51,680 NON-PHARMACOLOGICAL 6589 04:32:51,680 --> 04:32:52,640 INTERVENTIONS, REQUIRE TIME AND 6590 04:32:52,640 --> 04:32:53,080 EFFORT. 6591 04:32:53,080 --> 04:32:57,240 I KNOW I'M LOOKING AT STEVE 6592 04:32:57,240 --> 04:32:58,600 MESSIER, HE KNOWS FULL WELL HOW 6593 04:32:58,600 --> 04:33:00,520 MUCH WORK IT TAKES FROM THE 6594 04:33:00,520 --> 04:33:00,760 TEAM. 6595 04:33:00,760 --> 04:33:02,400 IF YOU'RE ONLY A SINGLE DOC OUT 6596 04:33:02,400 --> 04:33:05,360 THERE TRYING TO TREAT YOUR 6597 04:33:05,360 --> 04:33:07,120 PATIENTS, THAT'S A BIG LOAD. 6598 04:33:07,120 --> 04:33:10,160 YOU'RE NOT GETTING REIMBURSED 6599 04:33:10,160 --> 04:33:11,480 FOR ALL THOSE THINGS. 6600 04:33:11,480 --> 04:33:13,800 SO WE ARE THINKING ABOUT THIS 6601 04:33:13,800 --> 04:33:15,200 FROM THE HEALTH DISPARITIES 6602 04:33:15,200 --> 04:33:18,360 POINT OF VIEW, AND HOPING TO 6603 04:33:18,360 --> 04:33:19,480 BRING TOGETHER SEVERAL PARTNERS 6604 04:33:19,480 --> 04:33:23,200 TO TRY TO FIGURE OUT HOW TO BE 6605 04:33:23,200 --> 04:33:27,600 SURE THAT DOCTORS TREATING 6606 04:33:27,600 --> 04:33:38,040 PATIENTS FROM UNDERSERVED 6607 04:33:38,840 --> 04:33:40,000 COMMUNITIES HAVE ADEQUATE 6608 04:33:40,000 --> 04:33:41,800 REIMBURSEMENT TO BE ABLE TO 6609 04:33:41,800 --> 04:33:43,320 IMPART GUIDELINES THAT ARE 6610 04:33:43,320 --> 04:33:45,440 CURRENTLY AVAILABLE. 6611 04:33:45,440 --> 04:33:46,080 A GOOD POINT. 6612 04:33:46,080 --> 04:33:52,040 >>CUTTY, -- KATIE? 6613 04:33:52,040 --> 04:33:56,000 >>I THINK AMANDA IS ALLUDING TO 6614 04:33:56,000 --> 04:33:56,480 ADAPTIVE TRIALS. 6615 04:33:56,480 --> 04:34:01,640 MY PERSPECTIVE FROM LOW BACK 6616 04:34:01,640 --> 04:34:04,000 PAIN, NOT NECESSARILY 6617 04:34:04,000 --> 04:34:05,280 OSTEOARTHRITIS SPECIFICALLY, YOU 6618 04:34:05,280 --> 04:34:08,000 ABOUT THERE'S NICE WORK BY JULIE 6619 04:34:08,000 --> 04:34:09,120 FRITZ, DIFFERENT PATHWAYS 6620 04:34:09,120 --> 04:34:11,440 STARTING WITH A PHYSICAL THERAPY 6621 04:34:11,440 --> 04:34:14,080 INTERVENTION, SWITCHING TO 6622 04:34:14,080 --> 04:34:15,760 MINDFULNESS INTERVENTION THROUGH 6623 04:34:15,760 --> 04:34:16,920 PSYCHOLOGICAL SERVICES. 6624 04:34:16,920 --> 04:34:18,440 AND SO AGAIN NOT BEING STRUCK IN 6625 04:34:18,440 --> 04:34:19,040 ONE PATH. 6626 04:34:19,040 --> 04:34:22,680 I THINK SOME OTHER THINGS WE CAN 6627 04:34:22,680 --> 04:34:24,520 CONSIDER ARE LOOKING AT CLUSTER 6628 04:34:24,520 --> 04:34:26,120 RANDOMIZED TRIALS WHERE YOU'RE 6629 04:34:26,120 --> 04:34:29,320 LOOKING AT THE TRIAL FROM THE 6630 04:34:29,320 --> 04:34:31,520 CLINICAL -- LIKE THE CLINICAL 6631 04:34:31,520 --> 04:34:33,040 SITE PERSPECTIVE, SO THE 6632 04:34:33,040 --> 04:34:34,560 RANDOMIZATION IS DONE AT THE 6633 04:34:34,560 --> 04:34:36,400 CLINICAL SITE. 6634 04:34:36,400 --> 04:34:37,960 SEE THEN YOU AREN'T COMPARING 6635 04:34:37,960 --> 04:34:43,200 INTERVENTION TO INTERVENTION BT 6636 04:34:43,200 --> 04:34:44,240 PRACTICE TO PRACTICE, TRAINING 6637 04:34:44,240 --> 04:34:46,840 THE WHOLE ENTIRE GROUP OF 6638 04:34:46,840 --> 04:34:48,600 CLINICIANS TO APPROACH IT, TO 6639 04:34:48,600 --> 04:34:50,360 APPROACH THE INTERVENTION IN A 6640 04:34:50,360 --> 04:34:52,720 CERTAIN WAY OR DELIVER A PACKAGE 6641 04:34:52,720 --> 04:34:53,080 TO INTERVENTION. 6642 04:34:53,080 --> 04:34:54,320 AND THEN WHAT CAN YOU DO ON THE 6643 04:34:54,320 --> 04:34:57,240 BACK END WITH SOME OF THOSE 6644 04:34:57,240 --> 04:34:59,320 IMPLEMENTATION TYPE TRIALS LIKE 6645 04:34:59,320 --> 04:35:00,920 AHYBRID DESIGN, YOU'RE LOOKING 6646 04:35:00,920 --> 04:35:02,320 AT THE EFFECTIVENESS OF THE 6647 04:35:02,320 --> 04:35:04,920 INTERVENTION BUT ON THE BACK END 6648 04:35:04,920 --> 04:35:06,760 DO SECONDARY ANALYSES THAT LOOK 6649 04:35:06,760 --> 04:35:08,760 AT DIFFERENCES ACROSS THE 6650 04:35:08,760 --> 04:35:10,920 CLINICS AND TRACK SOME OF THOSE 6651 04:35:10,920 --> 04:35:12,760 ADAPTATIONS THAT MAYBE THE 6652 04:35:12,760 --> 04:35:13,760 CLINICIANS MADE TO THE 6653 04:35:13,760 --> 04:35:14,960 INTERVENTION BECAUSE OF THEIR 6654 04:35:14,960 --> 04:35:17,160 WORK FLOW OR BECAUSE OF THE TYPE 6655 04:35:17,160 --> 04:35:18,440 OF SUPPORT OR RESOURCES THEY HAD 6656 04:35:18,440 --> 04:35:19,640 AND THOSE CAN BE REALLY NICE 6657 04:35:19,640 --> 04:35:22,720 WAYS TO UNDERSTAND HOW TO GO 6658 04:35:22,720 --> 04:35:24,000 FORWARD NEXT IN ACTUALLY 6659 04:35:24,000 --> 04:35:26,000 IMPLEMENTING. 6660 04:35:26,000 --> 04:35:27,280 6661 04:35:27,280 --> 04:35:29,280 >>THANK YOU. 6662 04:35:29,280 --> 04:35:30,520 RICHARD, YOU HAVE A COMMENT? 6663 04:35:30,520 --> 04:35:34,480 >>YES, I WAS GOING TO SWITCH 6664 04:35:34,480 --> 04:35:36,400 THE CONVERSATION A BET TO 6665 04:35:36,400 --> 04:35:37,520 ADDRESS A COUPLE THINGS GAYLE 6666 04:35:37,520 --> 04:35:40,000 BROUGHT UP THAT I THINK ARE 6667 04:35:40,000 --> 04:35:41,040 REALLY IMPORTANT. 6668 04:35:41,040 --> 04:35:43,840 ONE IS ANIMAL MODELS. 6669 04:35:43,840 --> 04:35:46,240 AND BASIC SCIENCE RESEARCH. 6670 04:35:46,240 --> 04:35:49,560 FOR ANIMAL MODELS, I THINK A LOT 6671 04:35:49,560 --> 04:35:55,520 OF THE ISSUES HAVE BEEN AGE OF 6672 04:35:55,520 --> 04:35:56,920 ANIMALS RELATED TO 6673 04:35:56,920 --> 04:35:57,280 OSTEOARTHRITIS. 6674 04:35:57,280 --> 04:36:00,560 IN MICE IT'S BEEN EITHER MANY 6675 04:36:00,560 --> 04:36:01,200 TIMES, KNOCK OUTSTUDIES, 6676 04:36:01,200 --> 04:36:02,960 INJECTING INTO MOUSE JOINTS. 6677 04:36:02,960 --> 04:36:05,920 ALMOST ALWAYS THESE ARE LIKE 6678 04:36:05,920 --> 04:36:08,680 REALLY YOUNG MICE. 6679 04:36:08,680 --> 04:36:10,760 EQUIVALENT TO A TEENAGER. 6680 04:36:10,760 --> 04:36:11,840 YOUNG HUMANS REPAIR JOINTS MUCH 6681 04:36:11,840 --> 04:36:14,360 BETTER AS OPPOSED TO PEOPLE THAT 6682 04:36:14,360 --> 04:36:15,560 HAVE COMPLETED SKELETAL 6683 04:36:15,560 --> 04:36:15,880 DEVELOPMENT. 6684 04:36:15,880 --> 04:36:18,000 AND SO I THINK A LOT OF THE 6685 04:36:18,000 --> 04:36:19,200 ISSUES WITH PRE-CLINICAL STUDIES 6686 04:36:19,200 --> 04:36:20,800 HAVE BEEN RELATED TO THE AGE OF 6687 04:36:20,800 --> 04:36:24,080 THE ANIMALS AND THEN OF COURSE 6688 04:36:24,080 --> 04:36:26,560 IN MICE, MALE MICE GET MORE 6689 04:36:26,560 --> 04:36:28,840 SEVERE O.A. THAN FEMALE MICE, 6690 04:36:28,840 --> 04:36:30,360 MANY STUDIES ARE DONE MALE MICE. 6691 04:36:30,360 --> 04:36:31,920 WHEN YOU DO SOMETHING IN BOTH 6692 04:36:31,920 --> 04:36:35,840 SEXES YOU FIND SOME INTERESTING 6693 04:36:35,840 --> 04:36:36,200 DIFFERENCES. 6694 04:36:36,200 --> 04:36:38,720 SO, BOTH AGE AND SEX ARE REALLY 6695 04:36:38,720 --> 04:36:40,120 IMPORTANT, I THINK, FACTORS TO 6696 04:36:40,120 --> 04:36:42,200 CONSIDER IN THE PRE-CLINICAL 6697 04:36:42,200 --> 04:36:42,440 MODELS. 6698 04:36:42,440 --> 04:36:44,840 AND ALMOST ALL THE MODELS ARE 6699 04:36:44,840 --> 04:36:47,280 SINGLE MODEL WHERE IT'S A 6700 04:36:47,280 --> 04:36:48,560 SURGICALLY INDUCED O.A. 6701 04:36:48,560 --> 04:36:50,080 OBESITY MODELS ARE SO MUCH 6702 04:36:50,080 --> 04:36:52,000 HARDER TO STUDY BECAUSE IT TAKES 6703 04:36:52,000 --> 04:36:57,440 A LONG TIME FOR ANIMALS TO GET 6704 04:36:57,440 --> 04:36:59,040 OBESE ON HIGH FAT DIET, THERE 6705 04:36:59,040 --> 04:37:02,240 ARE WAYS TO SPEED IT UP. 6706 04:37:02,240 --> 04:37:06,480 WE NEED MORE BASIC SCIENCE 6707 04:37:06,480 --> 04:37:07,240 RESEARCH. 6708 04:37:07,240 --> 04:37:10,040 WE'VE IDENTIFIED TONS OF 6709 04:37:10,040 --> 04:37:11,960 CYTOKINES AND INFLAMMATORY 6710 04:37:11,960 --> 04:37:13,320 MEDIATORS PRESENT IN 6711 04:37:13,320 --> 04:37:22,440 OSTEOARTHRITIC JOINT COMING FROM 6712 04:37:22,440 --> 04:37:23,120 THESE TISSUES INVOLVED. 6713 04:37:23,120 --> 04:37:25,400 WE DON'T KNOW THE DRIVING 6714 04:37:25,400 --> 04:37:25,800 FACTOR. 6715 04:37:25,800 --> 04:37:33,200 WE DID STRANGE THINGS FOR FOR 6716 04:37:33,200 --> 04:37:36,600 PEOPLE WITH RHEUMATOID 6717 04:37:36,600 --> 04:37:44,280 ARTHRITIS, PARAFFIN BATHS, WENT 6718 04:37:44,280 --> 04:37:45,800 AWAY WHEN TNF INHIBITORS CAME 6719 04:37:45,800 --> 04:37:49,600 ALONG, MADE A HUGE DIFFERENCE IN 6720 04:37:49,600 --> 04:37:53,800 PEOPLE WITH RHEUMATOID ARTHRITIS 6721 04:37:53,800 --> 04:37:54,880 IN PAIN AND STRUCTURE. 6722 04:37:54,880 --> 04:37:57,000 I FEEL LIKE WE JUST HAVEN'T GOT 6723 04:37:57,000 --> 04:37:59,680 THERE YET IN TERMS OF WHAT IS 6724 04:37:59,680 --> 04:38:02,200 THE DRIVING FACTOR OR FACTORS IN 6725 04:38:02,200 --> 04:38:05,040 O.A. THAT IF WE CAN BLOCK THOSE 6726 04:38:05,040 --> 04:38:06,600 WE'LL HAVE A SIGNIFICANT EFFECT 6727 04:38:06,600 --> 04:38:07,920 ON PAIN AND STRUCTURE AND FOR 6728 04:38:07,920 --> 04:38:10,880 THAT REASON I FEEL LIKE WE DO 6729 04:38:10,880 --> 04:38:13,080 NEED MORE BASIC SCIENCE RESEARCH 6730 04:38:13,080 --> 04:38:15,040 SO THAT WE COULD IDENTIFY THAT. 6731 04:38:15,040 --> 04:38:17,960 AS YOU BROUGHT UP, SEVERAL 6732 04:38:17,960 --> 04:38:18,960 PEOPLE BROUGHT UP, INTERTISSUE 6733 04:38:18,960 --> 04:38:20,600 COMMUNICATION WITHIN THE JOINT 6734 04:38:20,600 --> 04:38:23,920 PROBABLY IS REALLY IMPORTANT IN 6735 04:38:23,920 --> 04:38:26,000 THAT TYPE OF DISCOVERY APPROACH. 6736 04:38:26,000 --> 04:38:30,000 SO I'LL STOP THERE. 6737 04:38:30,000 --> 04:38:31,200 >>THANK YOU. 6738 04:38:31,200 --> 04:38:31,640 >>THANKS, RICHARD. 6739 04:38:31,640 --> 04:38:32,960 >>YES, LET'S SEE. 6740 04:38:32,960 --> 04:38:34,400 LESLIE IS NEXT I THINK. 6741 04:38:34,400 --> 04:38:37,360 >>YEAH, I WANT TO COME BACK TO 6742 04:38:37,360 --> 04:38:39,880 THE ISSUE OF TREATMENT AND BACK 6743 04:38:39,880 --> 04:38:41,440 TO PREVENTION, PUT IN A PLUG IT 6744 04:38:41,440 --> 04:38:43,920 WOULD BE REALLY NICE TO BE ABLE 6745 04:38:43,920 --> 04:38:46,560 TO HAVE AN ANNUAL PREVENTIVE 6746 04:38:46,560 --> 04:38:47,520 CARE PHYSICAL THERAPY EVALUATION 6747 04:38:47,520 --> 04:38:49,840 FOR PATIENTS SO WE CAN IDENTIFY 6748 04:38:49,840 --> 04:38:50,920 PROBLEMS WHEN THEY ARE SMALL 6749 04:38:50,920 --> 04:38:55,080 BEFORE THEY GET TO THE BAD 6750 04:38:55,080 --> 04:38:56,960 PROBLEMS, THAT I'LL SOMETIMES 6751 04:38:56,960 --> 04:38:58,960 SEE PATIENTS HYPER MOBILE WHO 6752 04:38:58,960 --> 04:39:00,000 AREN'T SYMPTOMATIC YET, USUALLY 6753 04:39:00,000 --> 04:39:00,760 PARENTS BRINGING THEM IN BECAUSE 6754 04:39:00,760 --> 04:39:02,200 THEY ARE WORRIED ABOUT IT. 6755 04:39:02,200 --> 04:39:05,840 OH, WELL, BECAUSE YOU'VE GOT 6756 04:39:05,840 --> 04:39:07,600 IMBALANCES YOU'RE VULNERABLE TO 6757 04:39:07,600 --> 04:39:09,360 PROBLEMS, HERE ARE EXERCISES. 6758 04:39:09,360 --> 04:39:10,200 IF YOU FEEL THIS DEFINITELY LOOK 6759 04:39:10,200 --> 04:39:12,000 INTO IT. 6760 04:39:12,000 --> 04:39:13,720 WE COULD DO A BETTER JOB 6761 04:39:13,720 --> 04:39:15,160 PREVENTING AND PHYSICAL THERAPY 6762 04:39:15,160 --> 04:39:18,880 COULD BE INTEGRATED IN TO THAT 6763 04:39:18,880 --> 04:39:19,280 PREVENTIVE CARE. 6764 04:39:19,280 --> 04:39:22,280 >>THAT'S A GREAT IDEA, IF THIS 6765 04:39:22,280 --> 04:39:25,240 CAN BE LIKE YOUR ANNUAL DENTAL 6766 04:39:25,240 --> 04:39:26,680 EXAM OR SOMETHING. 6767 04:39:26,680 --> 04:39:30,720 AND IF WE HAD MEASUREMENTS, 6768 04:39:30,720 --> 04:39:31,680 OBJECTIVE MEASUREMENTS THAT 6769 04:39:31,680 --> 04:39:33,000 COULD BE COUPLED TO FOLLOW 6770 04:39:33,000 --> 04:39:36,360 PEOPLE OVER TIME, GREAT IDEA. 6771 04:39:36,360 --> 04:39:40,440 >>EVEN AS SIMPLE AS LEG LENGTH 6772 04:39:40,440 --> 04:39:42,600 DISCREPANCIES AND GAIT 6773 04:39:42,600 --> 04:39:43,720 ABNORMALITIES, YOU CAN SEE IN 6774 04:39:43,720 --> 04:39:46,440 THE PATIENT COULD BE ADDRESSED. 6775 04:39:46,440 --> 04:39:47,440 THAT'S A GREAT IDEA. 6776 04:39:47,440 --> 04:39:53,040 >>GREAT IDEA, YEAH. 6777 04:39:53,040 --> 04:39:53,280 ANN-MARIE? 6778 04:39:53,280 --> 04:39:54,040 >>THANK YOU. 6779 04:39:54,040 --> 04:39:58,920 I WANT TO GO BACK TO RICHARD'S 6780 04:39:58,920 --> 04:39:59,520 COMMENTS. 6781 04:39:59,520 --> 04:40:05,040 OF COURSE, I AGREE WITH RICHARD, 6782 04:40:05,040 --> 04:40:09,680 WE DO NEED TO HAVE MORE AND MORE 6783 04:40:09,680 --> 04:40:11,000 SOPHISTICATED BASIC SCIENCE 6784 04:40:11,000 --> 04:40:11,320 APPROACHES. 6785 04:40:11,320 --> 04:40:15,160 I JUST WANTED TO NUANCE A LITTLE 6786 04:40:15,160 --> 04:40:18,840 BIT, I DO NOT THINK WE HAVE 6787 04:40:18,840 --> 04:40:20,760 CURED O.A. IN ANIMALS ALL THE 6788 04:40:20,760 --> 04:40:21,400 TIME. 6789 04:40:21,400 --> 04:40:25,360 IF WE DO PROPER STUDIES IN 6790 04:40:25,360 --> 04:40:28,000 ANIMALS, IT'S EQUALLY HARD TO 6791 04:40:28,000 --> 04:40:31,600 EVEN ADDRESS THAT PAIN OR TO 6792 04:40:31,600 --> 04:40:32,560 AFFECT O.A. PROGRESSION, IT 6793 04:40:32,560 --> 04:40:34,920 RELATES TO EVERYTHING YOU 6794 04:40:34,920 --> 04:40:36,880 POINTED OUT, SO WE HAVE JUST ALL 6795 04:40:36,880 --> 04:40:39,600 MALE MICE AND DO THEM IN YOUNG 6796 04:40:39,600 --> 04:40:41,480 MICE AND IT'S ALL, YOU KNOW, 6797 04:40:41,480 --> 04:40:43,880 IT'S ALL QUITE EASY THE WAY IT'S 6798 04:40:43,880 --> 04:40:48,640 USUALLY DONE AND PEOPLE DO 6799 04:40:48,640 --> 04:40:49,800 PREVENTIVE PROPHYLACTIC 6800 04:40:49,800 --> 04:40:51,520 INTERVENTIONS, AND SO I WOULD 6801 04:40:51,520 --> 04:40:53,040 JUST ADD TO WHAT RICHARD SAID 6802 04:40:53,040 --> 04:41:03,560 THAT WE SHOULD REALLY HAVE THE 6803 04:41:04,520 --> 04:41:06,960 PATIENTS TO STUDY SLOWLY 6804 04:41:06,960 --> 04:41:08,720 PROGRESSIVE MODELS, EVEN IN 6805 04:41:08,720 --> 04:41:10,160 RODENTS TO COME IN AT TIME 6806 04:41:10,160 --> 04:41:12,000 POINTS AND DO THIS CAREFULLY 6807 04:41:12,000 --> 04:41:15,840 SO -- BECAUSE IF WE DO IT THAT 6808 04:41:15,840 --> 04:41:17,360 WAY, IT'S VERY DIFFICULT TO 6809 04:41:17,360 --> 04:41:21,560 REALLY CURE O.A. AND EVEN IN 6810 04:41:21,560 --> 04:41:25,040 MICE, EVEN WITH VERY GOOD 6811 04:41:25,040 --> 04:41:26,360 COMPOUNDS, WHAT WE SEE FOR 6812 04:41:26,360 --> 04:41:28,080 PROTECTION OF THE JOINTS AND ALL 6813 04:41:28,080 --> 04:41:30,920 THAT OVERALL IF YOU LOOK IN THE 6814 04:41:30,920 --> 04:41:33,000 LITERATURE IT'S NOT SO EASY TO 6815 04:41:33,000 --> 04:41:35,520 REALLY RESTORE THIS EVEN IN AN 6816 04:41:35,520 --> 04:41:35,880 ANIMAL. 6817 04:41:35,880 --> 04:41:38,080 AND SECONDLY, SOMETHING MAYBE 6818 04:41:38,080 --> 04:41:41,480 THAT WE HAVEN'T TALKED ABOUT, 6819 04:41:41,480 --> 04:41:43,120 ALSO RICHARD HIGHLIGHTED AND 6820 04:41:43,120 --> 04:41:45,080 THIS HAS COME UP OF COURSE A 6821 04:41:45,080 --> 04:41:46,280 LOT, INTERACTION BETWEEN THE 6822 04:41:46,280 --> 04:41:47,800 DIFFERENT TISSUES IS THAT WHAT 6823 04:41:47,800 --> 04:41:50,640 WE DIDN'T TALK ABOUT IS THAT 6824 04:41:50,640 --> 04:41:52,280 THERE ARE A LOT OF EFFORTS GOING 6825 04:41:52,280 --> 04:41:57,120 ON WHERE PEOPLE NOW DO THIS NOT 6826 04:41:57,120 --> 04:41:57,440 USING ANIMALS. 6827 04:41:57,440 --> 04:41:59,760 SO PEOPLE DEVELOP JOINTS ON A 6828 04:41:59,760 --> 04:42:00,040 CHIP. 6829 04:42:00,040 --> 04:42:01,840 IT'S ALL VERY EARLY DAYS, 6830 04:42:01,840 --> 04:42:03,760 LARGELY, BUT I THINK THAT WILL 6831 04:42:03,760 --> 04:42:07,200 ALSO HOLD A LOT OF PROMISE FOR 6832 04:42:07,200 --> 04:42:09,920 PEOPLE TO GO LOOK AT IN THE 6833 04:42:09,920 --> 04:42:10,160 FUTURE. 6834 04:42:10,160 --> 04:42:11,080 THOSE WERE MY TWO COMMENTS. 6835 04:42:11,080 --> 04:42:12,360 THANK YOU FOR THAT. 6836 04:42:12,360 --> 04:42:14,000 AND THANK YOU, EVERYBODY, FOR 6837 04:42:14,000 --> 04:42:19,040 THE PAST TWO VERY INTERESTING 6838 04:42:19,040 --> 04:42:19,240 DAYS. 6839 04:42:19,240 --> 04:42:20,560 >>THANK YOU. 6840 04:42:20,560 --> 04:42:21,960 >>GREAT. 6841 04:42:21,960 --> 04:42:22,160 ALEX? 6842 04:42:22,160 --> 04:42:24,840 >>YEAH, SO WE RECEIVED SOME 6843 04:42:24,840 --> 04:42:26,800 QUESTIONS FOR THIS GENERAL 6844 04:42:26,800 --> 04:42:27,800 DISCUSSION PRIOR TO THIS 6845 04:42:27,800 --> 04:42:30,000 AFTERNOON, AND I NOTICED SOME 6846 04:42:30,000 --> 04:42:31,840 COMMENTS RELATE TO QUESTION OR 6847 04:42:31,840 --> 04:42:33,040 FUTURE OPPORTUNITIES THAT DR. 6848 04:42:33,040 --> 04:42:33,480 STONE PRESENTED. 6849 04:42:33,480 --> 04:42:36,080 I'D LIKE TO INVITE DR. STONE IF 6850 04:42:36,080 --> 04:42:37,640 SHE'S AVAILABLE TO MAYBE ALSO 6851 04:42:37,640 --> 04:42:40,680 TALK ABOUT THE TRANSITION FOR 6852 04:42:40,680 --> 04:42:41,280 PRE-CLINICAL FINDINGS FROM 6853 04:42:41,280 --> 04:42:42,600 CLINICAL TRANSLATION AS WELL AS 6854 04:42:42,600 --> 04:42:47,360 MAYBE USE OF OTHER NON-RODENT 6855 04:42:47,360 --> 04:42:47,600 MODELS. 6856 04:42:47,600 --> 04:42:50,680 DR. STONE? 6857 04:42:50,680 --> 04:42:50,800 6858 04:42:50,800 --> 04:42:53,280 >>YEAH, THERE SHE IS. 6859 04:42:53,280 --> 04:42:59,800 >>YOU'RE MUTED, LAURA, IF YOU 6860 04:42:59,800 --> 04:43:00,400 COULD UNMUTE. 6861 04:43:00,400 --> 04:43:03,600 >>SO THERE WAS TWO QUESTIONS 6862 04:43:03,600 --> 04:43:04,080 THERE. 6863 04:43:04,080 --> 04:43:08,840 THE FIRST ON FACILITATING 6864 04:43:08,840 --> 04:43:12,560 TRANSLATIONAL FROM PRE-CLINICAL 6865 04:43:12,560 --> 04:43:15,520 STUDIES TO TRANSLATIONAL PICKSES 6866 04:43:15,520 --> 04:43:16,880 UP ON WHAT ANNE-MARIE JUST, I 6867 04:43:16,880 --> 04:43:18,840 THINK ONE OF THE BIG CHALLENGES 6868 04:43:18,840 --> 04:43:20,280 WITH OUR PRE-CLINICAL STUDIES BE 6869 04:43:20,280 --> 04:43:23,760 THEM IN RODENTS OR OTHER SPECIES 6870 04:43:23,760 --> 04:43:27,160 IS WE'RE NOT MODELING THE 6871 04:43:27,160 --> 04:43:27,800 CLINICAL SITUATION. 6872 04:43:27,800 --> 04:43:31,840 SO WE STUDY ONE DRUG AT A TIME 6873 04:43:31,840 --> 04:43:33,840 OR ONE INTERVENTION AT A TIME 6874 04:43:33,840 --> 04:43:34,480 WHERE INDIVIDUALS ARE DOING 6875 04:43:34,480 --> 04:43:36,800 MULTIPLE THINGS AT A TIME. 6876 04:43:36,800 --> 04:43:39,200 WE'RE STUDYING ANIMALS THAT ARE 6877 04:43:39,200 --> 04:43:43,640 NOT AT THE APPROPRIATE AGE. 6878 04:43:43,640 --> 04:43:45,520 WE'RE STUDYING MODELS THAT YOU 6879 04:43:45,520 --> 04:43:47,280 INDUCE A MODEL AND STUDY THE 6880 04:43:47,280 --> 04:43:49,280 ANIMAL A WEEK OR TWO LATER, 6881 04:43:49,280 --> 04:43:52,960 WHEREAS WE'RE TRYING TO MAKE 6882 04:43:52,960 --> 04:43:55,400 INFERENCES TO THESE COMPLEX 6883 04:43:55,400 --> 04:43:56,520 LONG-TERM PROGRESSIVE DISORDERS. 6884 04:43:56,520 --> 04:43:57,560 OUR TREATMENTS ARE NOT ON THE 6885 04:43:57,560 --> 04:43:59,960 RIGHT TIME FRAME AS WELL, SO NOT 6886 04:43:59,960 --> 04:44:02,400 ONLY ARE OUR MODELS NOT 6887 04:44:02,400 --> 04:44:04,160 REPRESENTING THE TIME FRAMES 6888 04:44:04,160 --> 04:44:14,600 BUT, YOU KNOW, THE COMMON 6889 04:44:15,920 --> 04:44:16,760 PRE-CLINICAL EXPERIMENT, INJECT 6890 04:44:16,760 --> 04:44:27,000 A DRUG, A WEEK 6891 04:45:15,400 --> 04:45:16,000 HUMAN. 6892 04:45:16,000 --> 04:45:19,920 I KNOW THE HEAL INITIATIVES HAS 6893 04:45:19,920 --> 04:45:24,880 CALLS OUT FOR NOT ONLY KIND OF 6894 04:45:24,880 --> 04:45:26,280 MORE VALID PRE-CLINICAL MODELS 6895 04:45:26,280 --> 04:45:29,800 THAT COULD BE RODENT OR NOT BUT 6896 04:45:29,800 --> 04:45:30,920 SPECIFICALLY FOR NON-RODENT SO I 6897 04:45:30,920 --> 04:45:32,520 REALLY HOPE YOU GET SOME GREAT 6898 04:45:32,520 --> 04:45:36,240 APPLICATION THERE IS BECAUSE WE 6899 04:45:36,240 --> 04:45:40,000 NEED SOMETHING IN BETWEEN, LIKE 6900 04:45:40,000 --> 04:45:41,360 WE'RE NOT REALLY TAKING 6901 04:45:41,360 --> 04:45:42,960 ADVANTAGE OF COMPANION ANIMAL 6902 04:45:42,960 --> 04:45:44,560 STUDIES, FOR EXAMPLE, FOR O.A. 6903 04:45:44,560 --> 04:45:46,400 OR BACK PAIN THE WAY THAT WE 6904 04:45:46,400 --> 04:45:48,160 REALLY COULD BE. 6905 04:45:48,160 --> 04:45:51,160 AND THAT'S AN OPPORTUNITY TO 6906 04:45:51,160 --> 04:45:53,840 TRANSITION PRE-CLINICAL STUDIES 6907 04:45:53,840 --> 04:45:56,520 INTO A MORE COMPLEX CLINICAL 6908 04:45:56,520 --> 04:45:58,760 UNIVERSE, PRIOR TO GOING TO 6909 04:45:58,760 --> 04:45:59,240 HUMANS. 6910 04:45:59,240 --> 04:46:00,440 AND SO IT WOULD BE REALLY NICE 6911 04:46:00,440 --> 04:46:02,400 TO SEE MAYBE SOME INITIATIVES, I 6912 04:46:02,400 --> 04:46:05,280 DON'T KNOW IF THIS IS SOMETHING 6913 04:46:05,280 --> 04:46:07,240 THAT COVERS "HEAL" FROM THE 6914 04:46:07,240 --> 04:46:08,480 COMMUNITY SHIFTS IN THIS 6915 04:46:08,480 --> 04:46:12,480 DIRECTION, BUT TO SEE MORE WORK 6916 04:46:12,480 --> 04:46:15,080 DONE AFTER RODENTS IN DOGS OR 6917 04:46:15,080 --> 04:46:22,600 CATS OR EVEN HORSES OR PIGS. 6918 04:46:22,600 --> 04:46:27,640 >>THANK YOU, LAURA. 6919 04:46:27,640 --> 04:46:28,880 SUCH AN IMPORTANT QUESTION ABOUT 6920 04:46:28,880 --> 04:46:31,400 THE ROLE OF LARGE ANIMAL MODELS, 6921 04:46:31,400 --> 04:46:33,800 ESPECIALLY SITUATIONS WHERE THE 6922 04:46:33,800 --> 04:46:34,440 MECHANICS ARE COMPARABLE TO 6923 04:46:34,440 --> 04:46:35,360 THAT. 6924 04:46:35,360 --> 04:46:39,240 THEY DON'T HAVE THE UPRIGHT 6925 04:46:39,240 --> 04:46:41,360 POSTURE, STILL IT'S A HUGE 6926 04:46:41,360 --> 04:46:42,880 INCREMENT BUT SO EXPENSIVE. 6927 04:46:42,880 --> 04:46:44,000 BUT VERY IMPORTANT. 6928 04:46:44,000 --> 04:46:52,000 SO, YEAH, THANK YOU. 6929 04:46:52,000 --> 04:46:53,600 KELSEY? 6930 04:46:53,600 --> 04:46:55,560 YOU HAD A DISMOMENT. 6931 04:46:55,560 --> 04:47:02,920 >> -- YOU HAD A COMMENT? 6932 04:47:02,920 --> 04:47:03,920 >>THINK WITH THINKING ABOUT 6933 04:47:03,920 --> 04:47:06,720 iPS CELLS AND EDITING THEM, 6934 04:47:06,720 --> 04:47:08,080 GREAT STUFF, IN MY MIND THE 6935 04:47:08,080 --> 04:47:09,680 BARRIER IS THAT JUST LIKE WHAT 6936 04:47:09,680 --> 04:47:11,920 WAS JUST MENTIONED THAT GETS US 6937 04:47:11,920 --> 04:47:14,280 ONE STEP AWAY FROM BEING ABLE TO 6938 04:47:14,280 --> 04:47:16,120 INCORPORATE THE PAIN OUTCOMES, 6939 04:47:16,120 --> 04:47:17,400 I'M CURIOUS FROM PEOPLE THAT ARE 6940 04:47:17,400 --> 04:47:18,440 THINKING ABOUT THIS AS AN 6941 04:47:18,440 --> 04:47:19,880 OPPORTUNITY HOW DO YOU SEE 6942 04:47:19,880 --> 04:47:27,120 BRIDGING THAT GAP OF GETTING ONE 6943 04:47:27,120 --> 04:47:28,520 STEP TOWARD MAYBE 6944 04:47:28,520 --> 04:47:29,400 HIGH-THROUGHPUT FEASIBILITY, WE 6945 04:47:29,400 --> 04:47:30,840 HAVE SOME TARGETS AND PATHWAYS 6946 04:47:30,840 --> 04:47:33,360 IN MIND FOR PAIN MEDIATORS BUT 6947 04:47:33,360 --> 04:47:35,000 MIGHT NOT BE THERE YET BUT I 6948 04:47:35,000 --> 04:47:37,280 AGREE THAT SUCH AN EXCITING 6949 04:47:37,280 --> 04:47:39,360 CONCEPT TO THINK ABOUT 6950 04:47:39,360 --> 04:47:44,000 ESPECIALLY IN THIS CAPACITY. 6951 04:47:44,000 --> 04:47:45,800 6952 04:47:45,800 --> 04:47:47,320 >>WELL, MAYBE FOCUSING ON 6953 04:47:47,320 --> 04:47:53,040 TISSUE HEALTH IS AN OPPORTUNITY 6954 04:47:53,040 --> 04:47:53,360 HERE, RIGHT? 6955 04:47:53,360 --> 04:47:56,000 THAT WHAT IS THE HEALTH OF A 6956 04:47:56,000 --> 04:47:58,800 CHIP, I DON'T KNOW, BUT THAT 6957 04:47:58,800 --> 04:48:01,000 WOULD -- ONE POSSIBILITY IS TO 6958 04:48:01,000 --> 04:48:04,760 USE THE CHIPS TO UNDERSTAND 6959 04:48:04,760 --> 04:48:09,640 BETTER THE INTERPLAY BETWEEN 6960 04:48:09,640 --> 04:48:10,960 VARIOUS DIFFERENT TISSUES, YOU 6961 04:48:10,960 --> 04:48:13,080 KNOW, UNDER VARIOUS AMOUNTS OF 6962 04:48:13,080 --> 04:48:14,040 VARIOUS DIFFERENT TYPES OF 6963 04:48:14,040 --> 04:48:15,680 MECHANICAL ENVIRONMENTS WHICH 6964 04:48:15,680 --> 04:48:17,960 YOU CAN DO NOW. 6965 04:48:17,960 --> 04:48:19,840 AND REALLY FOCUSING ON THAT AND 6966 04:48:19,840 --> 04:48:23,400 NOT SO MUCH ON -- WELL, YOU CAN 6967 04:48:23,400 --> 04:48:24,680 ADD SENSORY NEURONS TO IT BUT 6968 04:48:24,680 --> 04:48:26,120 CAN'T OBVIOUSLY MEASURE THE PAIN 6969 04:48:26,120 --> 04:48:27,080 OF A CHIP. 6970 04:48:27,080 --> 04:48:29,160 SO, YOU KNOW, THERE'S A LOT THAT 6971 04:48:29,160 --> 04:48:33,760 CAN BE DONE IN THESE IN VITRO 6972 04:48:33,760 --> 04:48:35,400 MODELS, BUT, YEAH, ANNE-MARIE, 6973 04:48:35,400 --> 04:48:38,040 YOU HAVE THOUGHTS? 6974 04:48:38,040 --> 04:48:38,640 6975 04:48:38,640 --> 04:48:43,120 >>YOU'RE MUTED. 6976 04:48:43,120 --> 04:48:44,000 YOU'RE MUTED. 6977 04:48:44,000 --> 04:48:46,600 >>YEAH, SORRY ABOUT THAT. 6978 04:48:46,600 --> 04:48:49,160 THIS SOUNDS CRAZY BUT I THINK IN 6979 04:48:49,160 --> 04:48:51,640 THE LONG RUN I HAVE HOPES THAT 6980 04:48:51,640 --> 04:48:54,360 WE MAY SEE THE PAIN ON THE CHIP. 6981 04:48:54,360 --> 04:48:57,040 AND I THINK THAT'S PARTIALLY 6982 04:48:57,040 --> 04:48:59,360 BECAUSE THAT'S PARTIALLY, I SAID 6983 04:48:59,360 --> 04:49:03,960 IN THE LONG RUN, BECAUSE IT'S 6984 04:49:03,960 --> 04:49:05,920 PARTIALLY WHAT, FOR EXAMPLE, 6985 04:49:05,920 --> 04:49:07,840 RE-JOIN IS TRYING TO DO. 6986 04:49:07,840 --> 04:49:10,000 IF WE ARE REALLY GOING TO SPEND, 6987 04:49:10,000 --> 04:49:11,800 AND WE ARE, A LOT OF -- MANY OF 6988 04:49:11,800 --> 04:49:17,400 US SPENDING A LOT OF MONEY TO 6989 04:49:17,400 --> 04:49:21,960 REALLY PROFILE AND VERY DETAILED 6990 04:49:21,960 --> 04:49:24,960 MANNER WE'RE PROFILING THE 6991 04:49:24,960 --> 04:49:26,520 MOLECULAR SIGNATURES OF THE 6992 04:49:26,520 --> 04:49:31,920 JOINTS, ALL THE TISSUES THE 6993 04:49:31,920 --> 04:49:33,160 JOINTS, DORSAL ROOT GANGLIA OF A 6994 04:49:33,160 --> 04:49:34,360 WHOLE NUMBER OF PATIENTS, 6995 04:49:34,360 --> 04:49:35,560 DIFFERENT SEXES, WE HAVE PAIN 6996 04:49:35,560 --> 04:49:37,120 INFORMATION OF THESE PEOPLE, 6997 04:49:37,120 --> 04:49:38,480 ANIMALS, WE'LL MAP ALL THIS. 6998 04:49:38,480 --> 04:49:41,480 SO HOPEFULLY FIVE YEARS FROM NOW 6999 04:49:41,480 --> 04:49:47,200 WE'LL HAVE ALL THAT. 7000 04:49:47,200 --> 04:49:48,760 IT MAY BE NAIVE BUT HOPEFULLY 7001 04:49:48,760 --> 04:49:49,920 LOOK AT A PROFILE. 7002 04:49:49,920 --> 04:49:51,240 ONE THING SO DIFFICULT WITH 7003 04:49:51,240 --> 04:49:54,160 PAIN, PEOPLE ALWAYS SAY WE HAVE 7004 04:49:54,160 --> 04:49:54,920 NO BIOMARKERS. 7005 04:49:54,920 --> 04:49:57,080 BUT THIS WOULD BE A VERY 7006 04:49:57,080 --> 04:49:59,480 SOPHISTICATED WAY OF SAYING WE 7007 04:49:59,480 --> 04:50:02,920 CAN LOOK AT THIS DRG PROFILE 7008 04:50:02,920 --> 04:50:04,560 STATE AND IT WILL TELL US 7009 04:50:04,560 --> 04:50:06,880 EXACTLY WHAT'S HAPPENING TO THAT 7010 04:50:06,880 --> 04:50:09,080 PATIENT, MAYBE TO THE JOINT. 7011 04:50:09,080 --> 04:50:11,040 I KNOW THAT'S VERY SIMPLIFIED 7012 04:50:11,040 --> 04:50:13,120 AND TAKES AWAY THE WHOLE, YOU 7013 04:50:13,120 --> 04:50:17,400 KNOW, THE PATIENT AS A PERSON, 7014 04:50:17,400 --> 04:50:20,000 BUT IN A VERY, YOU KNOW, IT'S 7015 04:50:20,000 --> 04:50:22,280 REDUCTIONIST AND AT THE SAME 7016 04:50:22,280 --> 04:50:26,480 TIME IT ISN'T. 7017 04:50:26,480 --> 04:50:34,160 IT'S ONE WAY WHERE WE CAN GO AND 7018 04:50:34,160 --> 04:50:36,440 THAT MAYBE IS OPTIMISTIC. 7019 04:50:36,440 --> 04:50:40,840 ONE REASON WE'RE DOING, RE-JOIN, 7020 04:50:40,840 --> 04:50:41,080 RIGHT? 7021 04:50:41,080 --> 04:50:41,960 MULTIPLE TARGET IDENTIFICATION, 7022 04:50:41,960 --> 04:50:43,480 ALSO TO REALLY PROFILE 7023 04:50:43,480 --> 04:50:45,000 EVERYTHING GOING ON IN PEOPLE, 7024 04:50:45,000 --> 04:50:45,240 UH-HUH. 7025 04:50:45,240 --> 04:50:47,120 >>YOU WOULD HAVE TO BUILD A 7026 04:50:47,120 --> 04:50:53,840 CHIP BASED ON ALL THAT 7027 04:50:53,840 --> 04:50:55,200 INFORMATION, WHY NOT? 7028 04:50:55,200 --> 04:50:59,240 >>GOOD POINT. 7029 04:50:59,240 --> 04:50:59,400 YES. 7030 04:50:59,400 --> 04:51:01,720 WHO ELSE HAS COMMENTS? 7031 04:51:01,720 --> 04:51:03,080 REACTIONS TO THIS? 7032 04:51:03,080 --> 04:51:04,360 OR TOPICS THAT WERE NOT YET 7033 04:51:04,360 --> 04:51:06,000 BROUGHT UP? 7034 04:51:06,000 --> 04:51:06,280 LET'S SEE. 7035 04:51:06,280 --> 04:51:09,840 >>I CAN DROP IN THE COMMENT 7036 04:51:09,840 --> 04:51:11,920 THAT DR. MESSIER HAD ABOUT 7037 04:51:11,920 --> 04:51:16,280 CHALLENGE BARRIER, NOTING THE 7038 04:51:16,280 --> 04:51:17,840 DILEMMA OF WEIGHT REGAIN. 7039 04:51:17,840 --> 04:51:19,000 >>OH, YEAH. 7040 04:51:19,000 --> 04:51:22,000 >>DID YOU WANT DR. MESSIER TO 7041 04:51:22,000 --> 04:51:23,440 EXPAND BEFORE WE -- 7042 04:51:23,440 --> 04:51:24,200 >>SURE, SURE. 7043 04:51:24,200 --> 04:51:27,120 >>DR. MESSIER, ARE YOU 7044 04:51:27,120 --> 04:51:28,040 AVAILABLE TO UNMUTE? 7045 04:51:28,040 --> 04:51:38,480 AND BRING UP YOUR VIDEO? 7046 04:51:41,480 --> 04:51:43,920 THERE YOU ARE. 7047 04:51:43,920 --> 04:51:44,560 >>YES. 7048 04:51:44,560 --> 04:51:47,480 WE HAD SOME SUCCESS IN THE 7049 04:51:47,480 --> 04:51:50,520 IDeA TRIAL, 3.5 YEARS AFTER 7050 04:51:50,520 --> 04:51:52,680 INTERVENTION, NO CONTACT WITH 7051 04:51:52,680 --> 04:51:55,760 THE PEOPLE. 7052 04:51:55,760 --> 04:51:57,240 AND THEY REGAINED ESSENTIALLY A 7053 04:51:57,240 --> 04:51:58,720 LITTLE OVER HALF THEIR WEIGHT 7054 04:51:58,720 --> 04:51:59,720 BACK. 7055 04:51:59,720 --> 04:52:05,040 SO THE QUESTION BECOMES REALLY 7056 04:52:05,040 --> 04:52:07,240 EVEN THOUGH 4, 6% WEIGHT LOSS 7057 04:52:07,240 --> 04:52:14,000 THAN FIVE YEARS BEFORE THAT, ARE 7058 04:52:14,000 --> 04:52:14,480 THEY REALLY HEALTHIER? 7059 04:52:14,480 --> 04:52:16,880 AND IN OTHER WORDS WAS IT WORTH 7060 04:52:16,880 --> 04:52:19,880 THEM GOING THROUGH THE WEIGHT 7061 04:52:19,880 --> 04:52:21,160 LOSS INTERVENTION? 7062 04:52:21,160 --> 04:52:28,720 3 1/2 YEARS AFTER IT WAS DONE? 7063 04:52:28,720 --> 04:52:32,000 AND SO TO ME, THERE WERE VARIOUS 7064 04:52:32,000 --> 04:52:36,560 WEIGHS, ESPECIALLY NOW WITH THE 7065 04:52:36,560 --> 04:52:37,320 PHARMACOLOGIC METHODS WE HAVE, I 7066 04:52:37,320 --> 04:52:39,480 THINK WE CAN GET PEOPLE TOE LOSE 7067 04:52:39,480 --> 04:52:39,880 WEIGHT. 7068 04:52:39,880 --> 04:52:44,320 I MEAN, WE'VE DONE IT A NUMBER 7069 04:52:44,320 --> 04:52:45,280 OF TIMES. 7070 04:52:45,280 --> 04:52:49,480 OTHER STUDIES HAVE DONE IT. 7071 04:52:49,480 --> 04:52:51,960 IT'S MAINTAIN THE WEIGHT LOSS 7072 04:52:51,960 --> 04:52:56,200 THAT IS THE HUGE QUESTION. 7073 04:52:56,200 --> 04:52:58,440 WHETHER IT IS -- WHETHER IT'S 7074 04:52:58,440 --> 04:53:03,280 WITH PEOPLE WHO ALREADY HAVE A 7075 04:53:03,280 --> 04:53:04,880 DISEASE OR PEOPLE WHO WE'RE 7076 04:53:04,880 --> 04:53:07,440 TRYING TO PREVENT A DISEASE FROM 7077 04:53:07,440 --> 04:53:07,720 HAPPENING. 7078 04:53:07,720 --> 04:53:12,000 AND SO THERE'S GOT TO BE A BIG 7079 04:53:12,000 --> 04:53:16,720 PSYCHOLOGICAL COMPONENT TO THAT. 7080 04:53:16,720 --> 04:53:18,040 BUT IT'S BAFFLING. 7081 04:53:18,040 --> 04:53:19,560 YOU KNOW, WE'RE NOT THE ONLY 7082 04:53:19,560 --> 04:53:20,880 ONES THAT TRIED TO DO THIS. 7083 04:53:20,880 --> 04:53:24,120 >>WELL, MAYBE IS IT POSSIBLE, 7084 04:53:24,120 --> 04:53:26,360 PEOPLE MAY NEED ONGOING SUPPORT. 7085 04:53:26,360 --> 04:53:27,920 MAY NOT BE REALISTIC TO ASSUME 7086 04:53:27,920 --> 04:53:29,880 PEOPLE CANNOT ONLY LOSE WEIGHT 7087 04:53:29,880 --> 04:53:35,600 BUT MAINTAIN THE WEIGHT LOSS 7088 04:53:35,600 --> 04:53:36,320 WITHOUT SUPPORT. 7089 04:53:36,320 --> 04:53:37,880 WE DON'T PROVIDE THAT. 7090 04:53:37,880 --> 04:53:41,200 WE DON'T REIMBURSE IT. 7091 04:53:41,200 --> 04:53:41,440 >>RIGHT. 7092 04:53:41,440 --> 04:53:43,680 >>THINK ABOUT HOW COST 7093 04:53:43,680 --> 04:53:44,640 EFFECTIVE THAT MIGHT BE. 7094 04:53:44,640 --> 04:53:46,640 >>THAT'S EXACTLY RIGHT. 7095 04:53:46,640 --> 04:53:49,120 AND OUR TRIALS WE HAVE A BIG 7096 04:53:49,120 --> 04:53:50,320 COST EFFECTIVE ANALYSIS IN ALL 7097 04:53:50,320 --> 04:53:51,760 OF OUR TRIALS. 7098 04:53:51,760 --> 04:53:53,680 >>YEAH, YOU PRESENTED THAT, 7099 04:53:53,680 --> 04:53:54,840 YEAH. 7100 04:53:54,840 --> 04:53:58,160 >>AND SO THE QUESTION IS, IF 7101 04:53:58,160 --> 04:53:59,600 YOU PROVIDE THAT SUPPORT THREE, 7102 04:53:59,600 --> 04:54:02,320 FIVE YEARS DOWN THE ROAD AFTER 7103 04:54:02,320 --> 04:54:03,960 THE INTERVENTION IS OVER, THEN 7104 04:54:03,960 --> 04:54:06,000 YOU ARE GOING TO GET CRITICIZED 7105 04:54:06,000 --> 04:54:09,800 FOR SAYING THAT'S NOT REALISTIC. 7106 04:54:09,800 --> 04:54:12,360 >>YEAH, BUT IF IT CAN BE SHOWN 7107 04:54:12,360 --> 04:54:14,200 ECONOMICALLY THAT IT SAVES SO 7108 04:54:14,200 --> 04:54:16,200 MANY HEALTH CARE COSTS LATER 7109 04:54:16,200 --> 04:54:20,000 DOWN THE ROAD, SAVE KNEE, JOINT 7110 04:54:20,000 --> 04:54:21,520 REPLACEMENT, ET CETERA, ET 7111 04:54:21,520 --> 04:54:23,880 CETERA, THAN THAT'S THE IDEA, 7112 04:54:23,880 --> 04:54:26,320 YOU COULD SHOW AN INVESTMENT IN 7113 04:54:26,320 --> 04:54:27,880 THE BEHAVIORAL CHANGE AND 7114 04:54:27,880 --> 04:54:29,680 MAINTENANCE OF THE BEHAVIORAL 7115 04:54:29,680 --> 04:54:33,640 CHANGE IS WORTH IT ECONOMICALLY 7116 04:54:33,640 --> 04:54:34,560 IN THE END. 7117 04:54:34,560 --> 04:54:39,600 >>YEAH, WE FEEL THAT WAY. 7118 04:54:39,600 --> 04:54:40,680 BUT OTHER PEOPLE DON'T. 7119 04:54:40,680 --> 04:54:42,960 >>HEALTH COACHING FOR EXAMPLE, 7120 04:54:42,960 --> 04:54:44,000 SOMEBODY'S MAKING A COMMENT IN 7121 04:54:44,000 --> 04:54:49,000 THE CHAT ABOUT HEALTH COACHING. 7122 04:54:49,000 --> 04:54:52,480 IT'S A RELATIVELY INEXPENSIVE 7123 04:54:52,480 --> 04:54:53,680 INTERVENTION THAT IF PROPERLY, 7124 04:54:53,680 --> 04:54:54,560 YOU KNOW, SUPPORTED AND 7125 04:54:54,560 --> 04:54:59,360 REIMBURSED COULD MAKE A BIG 7126 04:54:59,360 --> 04:55:01,440 DIFFERENCE LONG TERM. 7127 04:55:01,440 --> 04:55:01,680 SO, YES. 7128 04:55:01,680 --> 04:55:02,720 LET'S SEE. 7129 04:55:02,720 --> 04:55:04,760 DID SOMEBODY ELSE WANT TO 7130 04:55:04,760 --> 04:55:07,960 COMMENT ON THIS? 7131 04:55:07,960 --> 04:55:11,400 PREETI? 7132 04:55:11,400 --> 04:55:12,400 7133 04:55:12,400 --> 04:55:15,160 >>YEAH, HI. 7134 04:55:15,160 --> 04:55:16,640 I THINK THIS IS WHERE WE ARE 7135 04:55:16,640 --> 04:55:19,640 GOING WITH ALL OF THESE CHRONIC 7136 04:55:19,640 --> 04:55:22,520 DISEASES AND PAIN SEEMS TO BE 7137 04:55:22,520 --> 04:55:23,960 THAT THERE ARE PATIENTS AT HIGH 7138 04:55:23,960 --> 04:55:26,840 RISK, THAT MAY ACTUALLY NEED 7139 04:55:26,840 --> 04:55:31,280 INTERVENTIONS THAT ARE NOT JUST 7140 04:55:31,280 --> 04:55:32,680 ONE INTERVENTION BUT SOME KIND 7141 04:55:32,680 --> 04:55:34,200 OF LIFESTYLE COACH BECAUSE THAT 7142 04:55:34,200 --> 04:55:39,960 SEEMS TO BE ONE OF THE HARDEST 7143 04:55:39,960 --> 04:55:41,040 THINGS TO CHANGE BEHAVIOR. 7144 04:55:41,040 --> 04:55:43,280 >>YEAH. 7145 04:55:43,280 --> 04:55:43,960 EXACTLY. 7146 04:55:43,960 --> 04:55:45,600 YEAH, YEAH, YEAH. 7147 04:55:45,600 --> 04:55:46,120 KATIE? 7148 04:55:46,120 --> 04:55:47,320 >>YEAH, THANK YOU. 7149 04:55:47,320 --> 04:55:50,280 I WANTED TO COMMENT, THINK IT'S 7150 04:55:50,280 --> 04:55:52,240 A GREAT POINT THAT DR. 7151 04:55:52,240 --> 04:55:55,880 MESSIER -- DID I SAY IT RIGHT? 7152 04:55:55,880 --> 04:55:56,280 >>IT'S OKAY. 7153 04:55:56,280 --> 04:55:58,880 >>SO SORRY. 7154 04:55:58,880 --> 04:56:01,280 I'M MESSING UP EVERYONE'S NAME 7155 04:56:01,280 --> 04:56:01,920 TODAY. 7156 04:56:01,920 --> 04:56:03,080 THE POINT THAT THESE 7157 04:56:03,080 --> 04:56:05,720 INTERVENTIONS ARE NOT REALISTIC, 7158 04:56:05,720 --> 04:56:07,640 YOU KNOW, I THINK YOU BRING UP A 7159 04:56:07,640 --> 04:56:10,640 GREAT POINT BUT I THINK IF WE 7160 04:56:10,640 --> 04:56:12,640 CAN -- IT BECOMES A PROBLEM OF 7161 04:56:12,640 --> 04:56:16,920 HAVING -- OF TREATING A DISEASE 7162 04:56:16,920 --> 04:56:19,200 THAT ISN'T SEEN AS HAVING LIKE A 7163 04:56:19,200 --> 04:56:20,400 HIGH MORBIDITY OR MORTALITY 7164 04:56:20,400 --> 04:56:21,160 RATE, RIGHT? 7165 04:56:21,160 --> 04:56:24,000 SO LIKE IF WE'RE TREATING 7166 04:56:24,000 --> 04:56:26,920 CANCER, CANCER IS CONSIDERED 7167 04:56:26,920 --> 04:56:28,440 ESPECIALLY BREAST CANCER, 7168 04:56:28,440 --> 04:56:29,280 CONSIDERED LIKE LIFE-LONG 7169 04:56:29,280 --> 04:56:31,360 CONDITIONS THAT NEED TO BE 7170 04:56:31,360 --> 04:56:32,760 MANAGED, MONITORED, YOU'RE 7171 04:56:32,760 --> 04:56:35,160 LOOKING FOR RECURRENCE ALL THE 7172 04:56:35,160 --> 04:56:35,400 TIME. 7173 04:56:35,400 --> 04:56:35,920 AND NOBODY'S QUESTIONING 7174 04:56:35,920 --> 04:56:37,560 FOLLOWING UP WITH YOUR 7175 04:56:37,560 --> 04:56:39,320 ONCOLOGIST TEN YEARS LATER, 7176 04:56:39,320 --> 04:56:40,000 RIGHT? 7177 04:56:40,000 --> 04:56:43,440 SO YOU CAN -- THAT'S JUST HOW IT 7178 04:56:43,440 --> 04:56:44,120 IS. 7179 04:56:44,120 --> 04:56:45,960 AND CANCER-RELATED DISEASES. 7180 04:56:45,960 --> 04:56:50,080 SO I THINK HAVING A SHIFT IN 7181 04:56:50,080 --> 04:56:54,040 TERMS OF THINKING ABOUT PAIN AS 7182 04:56:54,040 --> 04:56:56,800 A DISEASE, JOINT HEALTH AS 7183 04:56:56,800 --> 04:57:01,520 DISEASES THAT REALLY AFFECT 7184 04:57:01,520 --> 04:57:02,880 MULTIPLE ASPECTS OF HUMAN 7185 04:57:02,880 --> 04:57:03,840 HEALTH, THINKING HOW WE CAN 7186 04:57:03,840 --> 04:57:05,400 PREVENT THAT. 7187 04:57:05,400 --> 04:57:07,720 I AGREE SOMETIMES WE'RE JUST 7188 04:57:07,720 --> 04:57:09,760 PUNISH -- - WHETHER IT'S HEALTH 7189 04:57:09,760 --> 04:57:11,400 CARE COMMUNITY OR SOCIETY WE'RE 7190 04:57:11,400 --> 04:57:15,600 NOT THERE YET IN TERMS OF 7191 04:57:15,600 --> 04:57:17,920 ACKNOWLEDGING THE HUGE BURDEN 7192 04:57:17,920 --> 04:57:22,800 THAT CHRONIC PAIN PUTS ON OUR 7193 04:57:22,800 --> 04:57:23,160 SOCIETY. 7194 04:57:23,160 --> 04:57:24,680 >>TOUCHED UPON SOMETHING VERY 7195 04:57:24,680 --> 04:57:25,880 IMPORTANT HERE, THAT AN 7196 04:57:25,880 --> 04:57:26,560 INTERVENTION LIKE HEALTH 7197 04:57:26,560 --> 04:57:28,680 COACHING, FOR EXAMPLE, MAY HELP 7198 04:57:28,680 --> 04:57:30,040 WITH PREVENTING, YOU KNOW, PAIN, 7199 04:57:30,040 --> 04:57:35,040 BUT IT COULD DO SO MUCH ELSE. 7200 04:57:35,040 --> 04:57:37,120 IT COULD PREVENT CARDIOVASCULAR 7201 04:57:37,120 --> 04:57:38,960 DISEASE, DIABETES, YOU KNOW, 7202 04:57:38,960 --> 04:57:43,840 PERHAPS EVEN DEPRESSION. 7203 04:57:43,840 --> 04:57:45,200 WE KNOW, FOR EXAMPLE, EXERCISE 7204 04:57:45,200 --> 04:57:50,280 IS PROTECTIVE FOR ALL THESE 7205 04:57:50,280 --> 04:57:51,080 FACTORS. 7206 04:57:51,080 --> 04:57:54,680 AND SO IT'S A BANG FOR THE BUCK, 7207 04:57:54,680 --> 04:57:55,320 AMAZING HOW EFFECTIVE IT COULD 7208 04:57:55,320 --> 04:58:01,240 BE IF IT COULD BE INVESTED UP 7209 04:58:01,240 --> 04:58:01,960 FRONT. 7210 04:58:01,960 --> 04:58:02,280 YEAH, LESLIE? 7211 04:58:02,280 --> 04:58:03,680 >>TO FOLLOW UP, THE U.S. RANKS 7212 04:58:03,680 --> 04:58:06,280 NEAR THE BOTTOM IN TERMS OF 7213 04:58:06,280 --> 04:58:08,400 HEALTH CARE QUALITY AND ACCESS 7214 04:58:08,400 --> 04:58:09,800 TO CARE, COMPARED TO OTHER 7215 04:58:09,800 --> 04:58:11,520 DEVELOPED COUNTRIES IN SPITE OF 7216 04:58:11,520 --> 04:58:13,520 THE MONEY WE SPEND. 7217 04:58:13,520 --> 04:58:16,480 I WORK WITH A LOT OF PEOPLE IN 7218 04:58:16,480 --> 04:58:17,000 EUROPE. 7219 04:58:17,000 --> 04:58:18,320 SOCIALIZED MEDICINE HAS SOME 7220 04:58:18,320 --> 04:58:19,520 GOOD THINGS IN TERMS OF 7221 04:58:19,520 --> 04:58:21,400 INTERPRETING OF PREVENTIVE CARE 7222 04:58:21,400 --> 04:58:22,480 LIKE HEALTH COACHING, PERHAPS WE 7223 04:58:22,480 --> 04:58:24,640 SHOULD BE LOOKING AT SOME OF THE 7224 04:58:24,640 --> 04:58:27,000 COUNTRIES THAT ARE MORE 7225 04:58:27,000 --> 04:58:27,960 SUCCESSFUL AT PROVIDING HEALTH 7226 04:58:27,960 --> 04:58:28,720 CARE THAN WE ARE. 7227 04:58:28,720 --> 04:58:31,560 AND SEE WHAT THEY ARE DOING 7228 04:58:31,560 --> 04:58:35,400 RIGHT. 7229 04:58:35,400 --> 04:58:41,440 7230 04:58:41,440 --> 04:58:42,640 >>PRETI, ANOTHER COMMENT? 7231 04:58:42,640 --> 04:58:45,040 >>DR. MESSIER'S FINDINGS ON 7232 04:58:45,040 --> 04:58:47,560 ATTENTION CONTROL BEING EQUALLY 7233 04:58:47,560 --> 04:58:48,880 EFFECTIVE, I DON'T KNOW THE 7234 04:58:48,880 --> 04:58:53,280 DETAILS, BUT THE IDEA OF 7235 04:58:53,280 --> 04:58:54,680 SOMEBODY BEING THERE TO HELP YOU 7236 04:58:54,680 --> 04:58:55,560 MAKE SURE YOU'RE DOING WHAT 7237 04:58:55,560 --> 04:58:57,720 YOU'RE SUPPOSED TO DO. 7238 04:58:57,720 --> 04:58:59,400 SOME PEOPLE NEED THAT FOR ANY 7239 04:58:59,400 --> 04:59:02,200 KIND OF -- THEY NEED THAT 7240 04:59:02,200 --> 04:59:04,400 STRUCTURE, NEED ACCOUNTABILITY. 7241 04:59:04,400 --> 04:59:07,200 AND SO PERHAPS THAT, THE 7242 04:59:07,200 --> 04:59:10,560 BEHAVIORAL, YOU KNOW, 7243 04:59:10,560 --> 04:59:11,800 MISSINGNESS THAT SOME PATIENTS 7244 04:59:11,800 --> 04:59:12,280 ABSOLUTELY NEED. 7245 04:59:12,280 --> 04:59:17,440 >>VERY, VERY GOOD POINT. 7246 04:59:17,440 --> 04:59:20,680 THIS PLACEBO, WHICH IS SUPPOSED 7247 04:59:20,680 --> 04:59:22,280 TO REALLY -- ATTENTION CONTROL 7248 04:59:22,280 --> 04:59:26,320 MAY BE ESSENTIALLY WHAT A HEALTH 7249 04:59:26,320 --> 04:59:27,880 COACH DOES. 7250 04:59:27,880 --> 04:59:29,320 YOU KNOW, MAYBE GIVING ADVICE 7251 04:59:29,320 --> 04:59:31,240 BUT MORE IMPORTANTLY A TOUCH 7252 04:59:31,240 --> 04:59:34,440 POINT FOR THE PERSON TO GET IN 7253 04:59:34,440 --> 04:59:39,400 TOUCH WITH NOW AND THEN. 7254 04:59:39,400 --> 04:59:40,920 >>WELL, ARE YOU TALKING 7255 04:59:40,920 --> 04:59:42,000 ABOUT -- WE'VE THOUGHT ABOUT 7256 04:59:42,000 --> 04:59:44,960 THIS, I'M NOT SKILLED IN THIS 7257 04:59:44,960 --> 04:59:46,240 AREA, BUT IMPLEMENTATION 7258 04:59:46,240 --> 04:59:46,480 SCIENCE. 7259 04:59:46,480 --> 04:59:46,720 >>YEAH. 7260 04:59:46,720 --> 04:59:50,440 >>YOU KNOW, SO WE HAVE DATA. 7261 04:59:50,440 --> 04:59:51,960 WE KNOW THESE THINGS WORK. 7262 04:59:51,960 --> 04:59:57,680 NOW CAN WE GET THEM INTO HEALTH 7263 04:59:57,680 --> 05:00:01,360 CARE SYSTEMS TO REALLY BE ABLE 7264 05:00:01,360 --> 05:00:03,080 TO MONITOR THESE PEOPLE LONG 7265 05:00:03,080 --> 05:00:03,440 TERM. 7266 05:00:03,440 --> 05:00:06,760 WE TRIED ONCE WE WENT THROUGH A 7267 05:00:06,760 --> 05:00:09,720 LOCAL HOSPITAL HERE IN NORTH 7268 05:00:09,720 --> 05:00:11,400 CAROLINA, AND THE CEO WAS ALL IN 7269 05:00:11,400 --> 05:00:11,920 ON IT. 7270 05:00:11,920 --> 05:00:14,640 AND WE DID A PILOT STUDY, AND 7271 05:00:14,640 --> 05:00:17,280 THEY WERE SO EXCITED ABOUT 7272 05:00:17,280 --> 05:00:20,000 GETTING DIET AND EXERCISE IN. 7273 05:00:20,000 --> 05:00:20,640 THEN HE RETIRED. 7274 05:00:20,640 --> 05:00:23,200 AND THAT WAS THE END. 7275 05:00:23,200 --> 05:00:25,160 YOU KNOW, BECAUSE THE NEXT 7276 05:00:25,160 --> 05:00:25,960 PERSON CAME IN, OH, NO, WE'RE 7277 05:00:25,960 --> 05:00:30,400 NOT GROWING -- GOING TO DO THI. 7278 05:00:30,400 --> 05:00:32,360 IT'S ALMOST LIKE YOU HAVE TO GET 7279 05:00:32,360 --> 05:00:34,800 SOMEONE AT THE TOP WHO BUYS IN, 7280 05:00:34,800 --> 05:00:36,160 HELPING TO RUN THE WHOLE THING. 7281 05:00:36,160 --> 05:00:38,760 IT WAS SUCH A DISHEARTENING 7282 05:00:38,760 --> 05:00:39,120 THING, YOU KNOW. 7283 05:00:39,120 --> 05:00:42,920 >>EVEN BETTER, SOMEBODY AT 7284 05:00:42,920 --> 05:00:43,760 CENTER FOR MEDICARE SERVICES. 7285 05:00:43,760 --> 05:00:44,160 >>RIGHT, YEAH. 7286 05:00:44,160 --> 05:00:44,880 >>THAT'S BEGINNING TO HAM. 7287 05:00:44,880 --> 05:00:46,480 I DON'T KNOW IF ANY OF YOU ARE 7288 05:00:46,480 --> 05:00:49,960 AWARE BUT THERE ARE TWO NEW 7289 05:00:49,960 --> 05:00:53,120 REIMBURSEMENT CODES NOW, CMS, IN 7290 05:00:53,120 --> 05:00:57,720 PLACE FOR ABOUT SIX MONTHS. 7291 05:00:57,720 --> 05:01:00,000 AND REIMBURSE PRIMARY CARE 7292 05:01:00,000 --> 05:01:03,240 PROVIDERS FOR DOING THE 7293 05:01:03,240 --> 05:01:05,040 EVALUATION AND REFERRALS TO THE 7294 05:01:05,040 --> 05:01:08,720 MULTIPLE DIFFERENT KINDS OF 7295 05:01:08,720 --> 05:01:10,600 PROVIDERS, YOU KNOW, NUTRITION, 7296 05:01:10,600 --> 05:01:11,120 PHYSICAL THERAPIST, HEALTH 7297 05:01:11,120 --> 05:01:11,960 COACH, ET CETERA. 7298 05:01:11,960 --> 05:01:14,200 DOESN'T GO AS FAR AS PAYING FOR 7299 05:01:14,200 --> 05:01:15,800 THOSE BUT SOME ARE ALREADY 7300 05:01:15,800 --> 05:01:16,200 REIMBURSED. 7301 05:01:16,200 --> 05:01:18,600 SOMEBODY WAS TALKING ABOUT THAT 7302 05:01:18,600 --> 05:01:19,920 EARLIER, ABOUT TAKING THE TIME 7303 05:01:19,920 --> 05:01:21,360 TO EVALUATE THE PATIENT. 7304 05:01:21,360 --> 05:01:24,200 I THINK DR. BROLINSON. 7305 05:01:24,200 --> 05:01:27,160 IT TAKES TIME, RIGHT, TO DO THE 7306 05:01:27,160 --> 05:01:29,440 BIOPSYCHOSOCIAL EVALUATION, 7307 05:01:29,440 --> 05:01:31,080 THAT'S RIGHT NOW, UNTIL NOW, 7308 05:01:31,080 --> 05:01:32,440 ESPECIALLY BUSY PRIMARY CARE 7309 05:01:32,440 --> 05:01:33,320 PROVIDERS ARE NOT REIMBURSED FOR 7310 05:01:33,320 --> 05:01:34,720 THAT BUT NOW THEY ARE. 7311 05:01:34,720 --> 05:01:37,560 IT'S VERY INTERESTING WHO IS 7312 05:01:37,560 --> 05:01:38,920 USING THESE CODES, PRIMARILY THE 7313 05:01:38,920 --> 05:01:42,720 PRIMARY CARE, NOT SO THE PAIN 7314 05:01:42,720 --> 05:01:43,040 SPECIALISTS. 7315 05:01:43,040 --> 05:01:45,600 SO INTERESTING TO FOLLOW WHAT 7316 05:01:45,600 --> 05:01:50,560 HAPPENS WITH THAT. 7317 05:01:50,560 --> 05:01:50,680 7318 05:01:50,680 --> 05:01:53,800 >>LOTS OF COMMENTS HERE. 7319 05:01:53,800 --> 05:01:59,840 7320 05:01:59,840 --> 05:02:00,040 KELSEY? 7321 05:02:00,040 --> 05:02:02,120 DO YOU WANT TO SAY YOUR COMMENT, 7322 05:02:02,120 --> 05:02:02,360 KELSEY? 7323 05:02:02,360 --> 05:02:03,160 >>SURE. 7324 05:02:03,160 --> 05:02:07,480 I WANTED TO CIRCLE BACK TO WHAT 7325 05:02:07,480 --> 05:02:12,000 WAS SAID ABOUT ROLE FOR ANIMAL 7326 05:02:12,000 --> 05:02:14,400 STUDIES ON A CHIP SYSTEM AND 7327 05:02:14,400 --> 05:02:19,880 OPPORTUNITY TO INTEGRATE 7328 05:02:19,880 --> 05:02:20,640 INTERVENTIONS AND MECHANISTIC 7329 05:02:20,640 --> 05:02:22,360 STUDIES, I WANTED TO EXPLORE A 7330 05:02:22,360 --> 05:02:23,520 LITTLE BIT MORE, SEE WHAT PEOPLE 7331 05:02:23,520 --> 05:02:26,000 THOUGHT GIVEN ALL OF THESE 7332 05:02:26,000 --> 05:02:27,760 CONFOUNDERS AND AGE, SEX, ALL OF 7333 05:02:27,760 --> 05:02:29,080 THIS GOOD STUFF, HOW WE COULD 7334 05:02:29,080 --> 05:02:32,000 MAYBE THINK ABOUT THIS TOGETHER 7335 05:02:32,000 --> 05:02:33,840 AND TAKE MORE COLLABORATIVE 7336 05:02:33,840 --> 05:02:35,960 APPROACH INSTEAD OF PROCEEDING 7337 05:02:35,960 --> 05:02:38,680 IN SILOS BY NECESSITY BECAUSE OF 7338 05:02:38,680 --> 05:02:41,960 FUNDING MECHANISM. 7339 05:02:41,960 --> 05:02:44,120 >>YES, I THINK YOUR RESEARCH 7340 05:02:44,120 --> 05:02:50,720 AND OTHERS WHO ARE DOING THIS 7341 05:02:50,720 --> 05:02:51,560 CROSS-SYSTEM, CROSS-TISSUE 7342 05:02:51,560 --> 05:02:54,560 CROSS-TALK IS REALLY OPEN BEING 7343 05:02:54,560 --> 05:02:57,240 A WHOLE AREA WHERE WE NEED THESE 7344 05:02:57,240 --> 05:03:00,200 KINDS OF APPROACHES TO DO THIS 7345 05:03:00,200 --> 05:03:00,640 JUSTICE. 7346 05:03:00,640 --> 05:03:05,440 AND TO MOVE THIS FORWARD. 7347 05:03:05,440 --> 05:03:06,040 ABSOLUTELY. 7348 05:03:06,040 --> 05:03:09,840 THIS NEEDS TO BE, ESPECIALLY IN 7349 05:03:09,840 --> 05:03:15,680 THE FIELD OF OBESITY, THE SEX 7350 05:03:15,680 --> 05:03:18,960 DIFFERENCES AND COMORBIDITIES 7351 05:03:18,960 --> 05:03:20,240 ARE SO BORN. 7352 05:03:20,240 --> 05:03:21,400 DOES ANYBODY ELSE HAVE THOUGHTS 7353 05:03:21,400 --> 05:03:21,920 ON THIS? 7354 05:03:21,920 --> 05:03:24,880 >>I WAS GOING TO SAY, KELSEY, 7355 05:03:24,880 --> 05:03:28,600 YOU KNOW, I THINK THESE ARE GOOD 7356 05:03:28,600 --> 05:03:32,600 IDEAS TO TAKE TO YOUR SOCIETY 7357 05:03:32,600 --> 05:03:33,400 RESEARCH SOCIETIES THAT YOU'RE 7358 05:03:33,400 --> 05:03:36,480 INVOLVED WITH AND TRY TO PUT 7359 05:03:36,480 --> 05:03:38,440 TOGETHER SOME WORKSHOPS, EVEN 7360 05:03:38,440 --> 05:03:44,000 PUTTING IN AN R13 TO NIH TO DO A 7361 05:03:44,000 --> 05:03:48,720 WORKSHOP, GETTING THESE GROUPS 7362 05:03:48,720 --> 05:03:49,680 TOGETHER TO GET 7363 05:03:49,680 --> 05:03:50,960 CROSS-FERTILIZATION OF IDEAS AND 7364 05:03:50,960 --> 05:03:52,880 APPROACHES IS REALLY A GOOD WAY 7365 05:03:52,880 --> 05:03:54,880 TO GO. 7366 05:03:54,880 --> 05:03:56,680 TEAM SCIENCE IS ANOTHER TERM FOR 7367 05:03:56,680 --> 05:03:58,800 WHAT YOU'RE TALKING ABOUT WHERE 7368 05:03:58,800 --> 05:04:01,960 YOU'VE GOT THE BASIC SCIENCE 7369 05:04:01,960 --> 05:04:06,000 FOLKS INFORMING THE CLINICAL AND 7370 05:04:06,000 --> 05:04:07,000 ANIMAL RESEARCH FOLKS, AND THEN 7371 05:04:07,000 --> 05:04:09,400 RESULTS COMING BACK TO THE BASIC 7372 05:04:09,400 --> 05:04:11,920 SCIENCE FOLKS AND KIND OF, YOU 7373 05:04:11,920 --> 05:04:13,120 KNOW, FORMING A TEAM THAT WORKS 7374 05:04:13,120 --> 05:04:15,560 TOGETHER AND TRIES TO SOLVE THE 7375 05:04:15,560 --> 05:04:15,800 PROBLEM. 7376 05:04:15,800 --> 05:04:17,760 SO I THINK YOU HAVE TO KIND OF 7377 05:04:17,760 --> 05:04:19,960 GENERATE A LITTLE BIT OF THAT 7378 05:04:19,960 --> 05:04:23,280 AND I DO THINK NIH IS REALLY ON 7379 05:04:23,280 --> 05:04:30,320 TO TEAM SCIENCE IN THAT REALM. 7380 05:04:30,320 --> 05:04:31,760 AND CERTAINLY INNOVATION. 7381 05:04:31,760 --> 05:04:34,040 SO I WOULD ENCOURAGE YOU TO 7382 05:04:34,040 --> 05:04:35,240 THINK ABOUT DOING THAT BECAUSE 7383 05:04:35,240 --> 05:04:35,800 CERTAINLY HAVE YOU THE 7384 05:04:35,800 --> 05:04:36,800 AMMUNITION WITH THE WORK YOU'RE 7385 05:04:36,800 --> 05:04:37,000 DOING. 7386 05:04:37,000 --> 05:04:41,400 >>THIS WAS ONE OF THE THEMES OF 7387 05:04:41,400 --> 05:04:44,120 THIS WORKSHOP, TO GET TOGETHER 7388 05:04:44,120 --> 05:04:46,120 PEOPLE FROM DIFFERENT FIELDS, 7389 05:04:46,120 --> 05:04:47,440 DIFFERENT AREAS, BOTH ON THE 7390 05:04:47,440 --> 05:04:50,040 BASIC SCIENCE SIDE AS WELL AS 7391 05:04:50,040 --> 05:04:51,640 CLINICAL SIDE, TO TALK. 7392 05:04:51,640 --> 05:04:54,080 I THINK FROM EVERYTHING THAT 7393 05:04:54,080 --> 05:04:55,920 WE'VE HEARD, I REALLY FEEL WE'VE 7394 05:04:55,920 --> 05:04:57,040 ACHIEVED THAT. 7395 05:04:57,040 --> 05:04:59,960 I DIDN'T POINT THAT OUT IN MY 7396 05:04:59,960 --> 05:05:01,920 REMARKS, TWO THREADS, TWO AREAS, 7397 05:05:01,920 --> 05:05:03,200 A NICE RESONANCE BETWEEN 7398 05:05:03,200 --> 05:05:04,280 YESTERDAY'S TALKS AND TODAY'S 7399 05:05:04,280 --> 05:05:04,680 TALKS. 7400 05:05:04,680 --> 05:05:09,760 ONE WAS IN THE AREA OF OBESITY 7401 05:05:09,760 --> 05:05:17,200 BECAUSE THAT GOT ADDRESSED AT 7402 05:05:17,200 --> 05:05:21,040 THE CELLULAR LEVEL, IN TERMS OF 7403 05:05:21,040 --> 05:05:23,680 PROFOUND INFLUENCE THAT ADIPOSE 7404 05:05:23,680 --> 05:05:25,240 TISSUE, ADIPOSE CELLS FROM 7405 05:05:25,240 --> 05:05:27,400 SYSTEMIC ASPECT IN TERMS OF 7406 05:05:27,400 --> 05:05:33,880 MECHANICAL ASPECT AS WELL AS 7407 05:05:33,880 --> 05:05:38,040 LOCAL PARACRINE ASPECT, HAVING 7408 05:05:38,040 --> 05:05:39,120 THAT ECHOED TODAY IN THE 7409 05:05:39,120 --> 05:05:41,680 CLINICAL STUDIES OF WEIGHT LOSS 7410 05:05:41,680 --> 05:05:42,960 AND EXERCISE. 7411 05:05:42,960 --> 05:05:44,720 AND THEN ANOTHER THREAD THAT WAS 7412 05:05:44,720 --> 05:05:52,000 CARRIED THROUGH ACROSS THE TWO 7413 05:05:52,000 --> 05:05:53,440 DAYS EXTRACELLULAR MATRIX 7414 05:05:53,440 --> 05:05:54,040 MECHANICAL ASPECTS, MOLECULAR 7415 05:05:54,040 --> 05:06:02,080 COMPONENT BUT AS WELL AS THE 7416 05:06:02,080 --> 05:06:08,920 SORT BIOMECHANICAL GROSS 7417 05:06:08,920 --> 05:06:13,280 CHARACTERISTICS OF THE TISSUE 7418 05:06:13,280 --> 05:06:16,160 IMAGING, SHEAR FORCES AND 7419 05:06:16,160 --> 05:06:16,400 STRENGTH. 7420 05:06:16,400 --> 05:06:17,800 I THINK FOR THOSE TWO, AND 7421 05:06:17,800 --> 05:06:19,000 OTHERS, JUST AN EXAMPLE OF TWO 7422 05:06:19,000 --> 05:06:24,000 AREAS WHERE I FELT THERE WAS A 7423 05:06:24,000 --> 05:06:24,960 NICE TRANSLATION ACROSS 7424 05:06:24,960 --> 05:06:26,800 DIFFERENT PARTS OF THE WORKSHOP, 7425 05:06:26,800 --> 05:06:28,400 I'M CURIOUS IF OTHER PEOPLE 7426 05:06:28,400 --> 05:06:30,440 NOTICED ANY OTHER AREAS WHERE 7427 05:06:30,440 --> 05:06:32,880 YOU FELT, OH, YOU KNOW, WHAT I 7428 05:06:32,880 --> 05:06:35,480 HEARD ON THE MECHANISTIC DAY, 7429 05:06:35,480 --> 05:06:40,200 DAY 1, OR MORE BASIC RESEARCH, 7430 05:06:40,200 --> 05:06:50,640 REALLY PLAYED INTO THE CLINICAL 7431 05:06:50,640 --> 05:06:53,120 AND VICE VERSA. 7432 05:06:53,120 --> 05:06:58,200 >>WE HAVE SOME QUESTIONS FROM 7433 05:06:58,200 --> 05:06:59,840 THE AUDIENCE, DR. LANGEVIN. 7434 05:06:59,840 --> 05:07:02,560 >>PLEASE GO AHEAD. 7435 05:07:02,560 --> 05:07:03,240 >>GREAT. 7436 05:07:03,240 --> 05:07:06,160 FIRST QUESTION, WHAT ROLE DO YOU 7437 05:07:06,160 --> 05:07:07,120 SEE FOR NON-TRADITIONAL 7438 05:07:07,120 --> 05:07:08,080 PRACTICES OR INTERVENTION IN 7439 05:07:08,080 --> 05:07:10,080 EARLY PREVENTION AND LATER 7440 05:07:10,080 --> 05:07:12,080 TREATMENT OF OSTEOARTHRITIS IN 7441 05:07:12,080 --> 05:07:14,120 FOR EXAMPLE, YOGA MOVEMENT COULD 7442 05:07:14,120 --> 05:07:15,640 BE HELPFUL IN DEVELOPING OR 7443 05:07:15,640 --> 05:07:16,400 CORRECTING BODY MECHANICS, AND 7444 05:07:16,400 --> 05:07:19,360 WHAT ABOUT THE WHOLE INDUSTRY OF 7445 05:07:19,360 --> 05:07:20,960 SUPPLEMENTS INCLUDING HERBAL 7446 05:07:20,960 --> 05:07:29,400 THERAPIES, ET CETERA? 7447 05:07:29,400 --> 05:07:29,800 7448 05:07:29,800 --> 05:07:32,360 >>I THINK THAT'S YOUR QUESTION, 7449 05:07:32,360 --> 05:07:32,680 HELL EARNINGS? 7450 05:07:32,680 --> 05:07:33,720 >>HERBAL THERAPIES? 7451 05:07:33,720 --> 05:07:36,840 WE DIDN'T TALK ABOUT THAT MUCH, 7452 05:07:36,840 --> 05:07:38,760 CERTAINLY AN AREA, THE WHOLE 7453 05:07:38,760 --> 05:07:41,080 THING WITH HERBAL, THE 7454 05:07:41,080 --> 05:07:42,400 INTERESTING THING ABOUT 7455 05:07:42,400 --> 05:07:44,400 BOTANICALS AND DIETARY 7456 05:07:44,400 --> 05:07:51,960 SUPPLEMENTS IS THAT THERE'S A 7457 05:07:51,960 --> 05:07:53,360 DIFFERENCE BETWEEN TAKING A 7458 05:07:53,360 --> 05:07:55,000 SUPPLEMENT AS A REPLACEMENT TO 7459 05:07:55,000 --> 05:07:56,640 CORRECT LIKE A DEFICIENCY AND 7460 05:07:56,640 --> 05:07:59,440 ALSO OR TAKING IT IN LARGER DOSE 7461 05:07:59,440 --> 05:08:02,400 TO ACT MORE LIKE A DRUG, YOU 7462 05:08:02,400 --> 05:08:04,640 KNOW, HAVING A TARGETED 7463 05:08:04,640 --> 05:08:06,960 BIOLOGICAL EFFECT. 7464 05:08:06,960 --> 05:08:08,520 AND SO THERE'S TWO DIFFERENT 7465 05:08:08,520 --> 05:08:16,440 WAYS TO THINK ABOUT THIS. 7466 05:08:16,440 --> 05:08:18,080 WE DIDN'T COVER A LOT TODAYN 7467 05:08:18,080 --> 05:08:19,800 THIS WORKSHOP, BUT IT'S AN AREA 7468 05:08:19,800 --> 05:08:21,480 WHEN YOU THINK ABOUT 7469 05:08:21,480 --> 05:08:22,400 MULTI-COMPONENT INTERVENTIONS 7470 05:08:22,400 --> 05:08:24,600 YOU COULD HAVE NUTRITIONAL 7471 05:08:24,600 --> 05:08:30,040 COMPONENT THAT WOULD NOT BE 7472 05:08:30,040 --> 05:08:31,920 SIMPLY BALANCED DIET AND CUT 7473 05:08:31,920 --> 05:08:34,880 BACK CALORIES, COULD BE 7474 05:08:34,880 --> 05:08:35,720 NUTRIENTS OR NON-NUTRIENTS, 7475 05:08:35,720 --> 05:08:37,960 COMPONENTS OF DIET THAT COULD BE 7476 05:08:37,960 --> 05:08:39,360 TESTED AS WELL. 7477 05:08:39,360 --> 05:08:41,440 I JUST SAW -- OOPS. 7478 05:08:41,440 --> 05:08:43,080 >>THE OTHER PART OF THE 7479 05:08:43,080 --> 05:08:45,480 QUESTION WAS THE PERSON ASKING 7480 05:08:45,480 --> 05:08:47,920 ABOUT GENERALLY THE ROLE FOR 7481 05:08:47,920 --> 05:08:50,160 NON-TRADITIONAL PRACTICES OR 7482 05:08:50,160 --> 05:08:51,080 INTERVENTIONS IN EARLY 7483 05:08:51,080 --> 05:09:00,040 PREVENTION, THEY ALSO NOTED 7484 05:09:00,040 --> 05:09:00,680 SOMETHING LIKE YOGA. 7485 05:09:00,680 --> 05:09:01,520 >>EXERCISE THERAPY. 7486 05:09:01,520 --> 05:09:02,760 >>WE TALKED ABOUT EXERCISE. 7487 05:09:02,760 --> 05:09:05,600 THERE WAS NOT ANY DISCUSSION OF 7488 05:09:05,600 --> 05:09:07,720 YOGA TODAY. 7489 05:09:07,720 --> 05:09:09,560 BUT CERTAINLY YOGA INCORPORATION 7490 05:09:09,560 --> 05:09:13,520 A LOT OF ELEMENTS. 7491 05:09:13,520 --> 05:09:15,480 THERE'S BASICALLY THE PHYSICAL 7492 05:09:15,480 --> 05:09:17,080 ACTIVITY COMPONENT, A STRETCHING 7493 05:09:17,080 --> 05:09:17,360 COMPONENT. 7494 05:09:17,360 --> 05:09:19,960 WE DIDN'T TALK ABOUT STRETCHING 7495 05:09:19,960 --> 05:09:22,360 TODAY BUT WHEN YOU TALK ABOUT 7496 05:09:22,360 --> 05:09:25,480 TISSUE PLANES THAT MAY HAVE 7497 05:09:25,480 --> 05:09:27,840 BECOME STIFF OR ADHERENT, 7498 05:09:27,840 --> 05:09:30,800 APPLYING STRETCHING THAT, YOU 7499 05:09:30,800 --> 05:09:32,120 KNOW, CREATES SOME SHEAR STRAIN 7500 05:09:32,120 --> 05:09:34,760 BETWEEN THE LAYERS OF TISSUE 7501 05:09:34,760 --> 05:09:35,720 ESPECIALLY CONNECTIVE TISSUE, 7502 05:09:35,720 --> 05:09:43,520 THAT COULD HAVE SOME VERY 7503 05:09:43,520 --> 05:09:45,920 IMPORTANT EFFECTS THAT WE DON'T 7504 05:09:45,920 --> 05:09:46,120 KNOW. 7505 05:09:46,120 --> 05:09:49,680 ONE COMPLEMENTARY MODALITY SHOWN 7506 05:09:49,680 --> 05:09:53,720 OVER AND OVER AGAIN TO BE 7507 05:09:53,720 --> 05:09:55,840 BENEFICIAL IS TAI CHI, EVEN MORE 7508 05:09:55,840 --> 05:09:59,440 THAN YOGA, THE THING ABOUT TAI 7509 05:09:59,440 --> 05:10:01,200 CHI IS THAT IT'S NOT EXTREME 7510 05:10:01,200 --> 05:10:02,520 STRETCHING, GOES THROUGH A RANGE 7511 05:10:02,520 --> 05:10:04,880 OF BEYOND PERHAPS WHAT THEY DO 7512 05:10:04,880 --> 05:10:06,360 IN THEIR EVERYDAY LIVES, BUT 7513 05:10:06,360 --> 05:10:07,640 DOESN'T STRETCH THE TISSUES TO 7514 05:10:07,640 --> 05:10:09,280 THE POINT OF INJURING THEM WHICH 7515 05:10:09,280 --> 05:10:11,440 SOMETIMES HAPPENS WITH YOGA, SO 7516 05:10:11,440 --> 05:10:14,400 IT'S VERY SAFE AND THERE'S ALSO 7517 05:10:14,400 --> 05:10:16,000 A CARDIOVASCULAR COMPONENT TO 7518 05:10:16,000 --> 05:10:23,920 TAI CHI, THAT HAS BEEN SHOWN TO 7519 05:10:23,920 --> 05:10:25,160 BE BENEFICIAL. 7520 05:10:25,160 --> 05:10:26,920 THE OTHER THING ABOUT YOGA AND 7521 05:10:26,920 --> 05:10:30,960 TAI CHI, THERE'S A NEURAL 7522 05:10:30,960 --> 05:10:31,560 COMPONENT, AWARENESS, SENSORY 7523 05:10:31,560 --> 05:10:33,360 AWARENESS THAT PROBABLY FEEDS 7524 05:10:33,360 --> 05:10:34,280 INTO PROPRIOCEPTION, WE TALKED 7525 05:10:34,280 --> 05:10:35,680 ABOUT THAT YESTERDAY. 7526 05:10:35,680 --> 05:10:38,200 WE TALKED ABOUT BECOMING AWARE 7527 05:10:38,200 --> 05:10:41,360 OF ONE'S JOINT POSITION IN 7528 05:10:41,360 --> 05:10:42,960 SPACE, AND THERE HASN'T BEEN 7529 05:10:42,960 --> 05:10:44,680 DETAILED STUDIES OF THIS BUT 7530 05:10:44,680 --> 05:10:46,600 CERTAINLY HELPS WITH BALANCE, SO 7531 05:10:46,600 --> 05:10:47,520 PROBABLY HELPS WITH 7532 05:10:47,520 --> 05:10:48,600 PROPRIOCEPTION AS WELL, WOULDN'T 7533 05:10:48,600 --> 05:10:51,320 BE SURPRISED IF THAT WAS 7534 05:10:51,320 --> 05:10:54,960 MEASURED IN DETAIL IN TERMS OF 7535 05:10:54,960 --> 05:10:56,640 EFFECT ON JOINT PROPRIOCEPTION, 7536 05:10:56,640 --> 05:10:58,120 MIGHT HAVE AN EFFECT BUT NO 7537 05:10:58,120 --> 05:11:07,240 SPECIFIC RESEARCH THAT I KNOW OF 7538 05:11:07,240 --> 05:11:07,640 ON THIS. 7539 05:11:07,640 --> 05:11:08,840 IS THAT THE WHOLE QUESTION? 7540 05:11:08,840 --> 05:11:09,480 A LOT OF QUESTIONS. 7541 05:11:09,480 --> 05:11:15,960 >>THAT IS THE QUESTION. 7542 05:11:15,960 --> 05:11:19,440 ANOTHER QUESTION FROM DR. 7543 05:11:19,440 --> 05:11:20,000 WILLIAMS, DR. BROOKS. 7544 05:11:20,000 --> 05:11:22,840 ALEX, DID YOU WANT TO POSE THAT 7545 05:11:22,840 --> 05:11:23,120 QUESTION? 7546 05:11:23,120 --> 05:11:24,600 >>DR. BROOKS MENTIONED MAYBE A 7547 05:11:24,600 --> 05:11:26,440 FRAME SHIFT TO CONSIDER NOT ONLY 7548 05:11:26,440 --> 05:11:29,440 THE JOINT AS AN ORGAN BUT ALL OF 7549 05:11:29,440 --> 05:11:31,280 THE MUSCULOSKELETAL JOINTS AS 7550 05:11:31,280 --> 05:11:32,760 COMPONENTS OF ORGAN SYSTEM 7551 05:11:32,760 --> 05:11:34,280 GENERATING HUMAN POSTURE AND 7552 05:11:34,280 --> 05:11:34,680 MOVEMENT. 7553 05:11:34,680 --> 05:11:36,680 IS THERE AN OPTIMAL OR HEALTHY 7554 05:11:36,680 --> 05:11:38,080 AMOUNT OF MOVEMENT OR POSTURE AS 7555 05:11:38,080 --> 05:11:39,600 A WHOLE SYSTEM? 7556 05:11:39,600 --> 05:11:42,120 IS THAT SOMETHING THAT THE 7557 05:11:42,120 --> 05:11:43,680 PANELISTS COULD MAYBE DISCUSS OR 7558 05:11:43,680 --> 05:11:45,680 THINK ABOUT? 7559 05:11:45,680 --> 05:11:48,920 I THOUGHT OF IT WITH TAI CHI. 7560 05:11:48,920 --> 05:11:49,880 >>INTERESTING QUESTION. 7561 05:11:49,880 --> 05:11:51,280 ANYBODY HAVE THOUGHTS? 7562 05:11:51,280 --> 05:11:53,200 YOU'RE TALKING WHOLE BOUGHT, NOT 7563 05:11:53,200 --> 05:11:54,200 JUST WHOLE JOINT, RIGHT? 7564 05:11:54,200 --> 05:11:54,800 >>RIGHT. 7565 05:11:54,800 --> 05:11:55,440 >>WHOLE BODY. 7566 05:11:55,440 --> 05:11:57,440 >>LIKE A JOINT SYSTEM, YES. 7567 05:11:57,440 --> 05:11:59,480 >>YEAH, YEAH. 7568 05:11:59,480 --> 05:12:01,480 LESLIE? 7569 05:12:01,480 --> 05:12:03,080 >>YEAH, THERE'S A FAIR AMOUNT 7570 05:12:03,080 --> 05:12:05,520 OF RESEARCH THAT SHOWS THAT 7571 05:12:05,520 --> 05:12:07,400 THOSE FULL BODY MOVEMENT ARTS 7572 05:12:07,400 --> 05:12:10,880 ARE BENEFICIAL FOR THINGS LIKE 7573 05:12:10,880 --> 05:12:13,000 BALANCE, BUT ALSO FOR DECREASING 7574 05:12:13,000 --> 05:12:17,240 STRESS WHICH CAN BE HELPFUL FOR 7575 05:12:17,240 --> 05:12:22,360 DECREASING PAIN AND POTENTIALLY 7576 05:12:22,360 --> 05:12:25,360 DECREASING INFLAMMATION, SO FULL 7577 05:12:25,360 --> 05:12:26,840 BODY MIND-BODY MOVEMENT ARTS 7578 05:12:26,840 --> 05:12:28,560 DEFINITELY HAVE A ROLE, AND 7579 05:12:28,560 --> 05:12:35,920 PHYSICAL THERAPISTS ARE 7580 05:12:35,920 --> 05:12:37,880 INTEGRATING THEM BECAUSE THEY 7581 05:12:37,880 --> 05:12:38,880 ARE HOLISTIC AND PEOPLE CAN 7582 05:12:38,880 --> 05:12:40,600 CONTINUE ON THEIR OWN AND NOT 7583 05:12:40,600 --> 05:12:44,880 NEED THE HEALTH HEALTH CARE SYO 7584 05:12:44,880 --> 05:12:47,120 PARTICIPATE IN. 7585 05:12:47,120 --> 05:12:52,960 >>ANYBODY ELSE? 7586 05:12:52,960 --> 05:12:54,360 THERE'S A GENERAL QUESTION THAT 7587 05:12:54,360 --> 05:12:58,240 THE CHAIRS MIGHT BE ABLE TO 7588 05:12:58,240 --> 05:12:59,240 ANSWER, FROM KAREN. 7589 05:12:59,240 --> 05:13:00,600 INTERESTED IN HOW PATIENTS AND 7590 05:13:00,600 --> 05:13:01,440 OTHER INTERESTED PARTIES CAN 7591 05:13:01,440 --> 05:13:03,600 CONTRIBUTE TO THE SCIENCE AND 7592 05:13:03,600 --> 05:13:05,640 IMPROVING PATIENT CARE BEYOND 7593 05:13:05,640 --> 05:13:06,720 PARTICIPATING DIRECTLY IN 7594 05:13:06,720 --> 05:13:15,360 CLINICAL TRIALS. 7595 05:13:15,360 --> 05:13:15,720 7596 05:13:15,720 --> 05:13:17,680 >>I'M SORRY, CAN YOU REPEAT 7597 05:13:17,680 --> 05:13:17,880 THAT? 7598 05:13:17,880 --> 05:13:18,840 >>INTERESTED MEMBER OF THE 7599 05:13:18,840 --> 05:13:21,520 PUBLIC HOW THEY CAN BE INVOLVED 7600 05:13:21,520 --> 05:13:22,360 IN SCIENCE BESIDES DOING 7601 05:13:22,360 --> 05:13:22,840 CLINICAL TRIALS. 7602 05:13:22,840 --> 05:13:24,920 >>OH, HOW THE PUBLIC CAN BE 7603 05:13:24,920 --> 05:13:25,680 INVOLVED? 7604 05:13:25,680 --> 05:13:29,320 WELL, THERE'S A BIG -- THERE'S A 7605 05:13:29,320 --> 05:13:31,560 LOT OF INCREASED AWARENESS OF 7606 05:13:31,560 --> 05:13:34,000 THE IMPORTANCE OF PATIENT -- 7607 05:13:34,000 --> 05:13:35,160 PUBLIC ENGAGEMENT, RIGHT? 7608 05:13:35,160 --> 05:13:36,640 IN DOING EXACTLY WHAT YOU'RE 7609 05:13:36,640 --> 05:13:39,440 DOING NOW, PARTICIPATING IN 7610 05:13:39,440 --> 05:13:41,120 THESE TYPES OF CONFERENCES AND 7611 05:13:41,120 --> 05:13:44,720 REALLY HELPING YOU ILLUMINATE 7612 05:13:44,720 --> 05:13:45,760 IMPORTANT RESEARCH QUESTIONS 7613 05:13:45,760 --> 05:13:49,080 THAT MATTER TO YOU, AS A 7614 05:13:49,080 --> 05:13:50,960 PATIENT, SO PATIENT ENGAGEMENT 7615 05:13:50,960 --> 05:13:52,080 IN RESEARCH IS EXTREMELY 7616 05:13:52,080 --> 05:13:56,520 IMPORTANT, NOT JUST IN BEING A 7617 05:13:56,520 --> 05:13:59,600 VOLUNTEER OR PARTICIPANT BUT 7618 05:13:59,600 --> 05:14:02,880 ALSO HELPING TO ASK THE RIGHT 7619 05:14:02,880 --> 05:14:03,160 QUESTIONS. 7620 05:14:03,160 --> 05:14:06,640 >>I THINK THERE ARE ROLES FOR 7621 05:14:06,640 --> 05:14:10,080 THE PUBLIC IN ORGANIZATIONS LIKE 7622 05:14:10,080 --> 05:14:11,480 ARTHRITIS FOUNDATION, 7623 05:14:11,480 --> 05:14:13,400 FOUNDATIONS THAT ARE FOCUSED ON 7624 05:14:13,400 --> 05:14:15,680 ALMOST EVERY DISEASE AND 7625 05:14:15,680 --> 05:14:15,960 DISORDER. 7626 05:14:15,960 --> 05:14:17,920 AND THIS DO A LOT OF TRYING TO 7627 05:14:17,920 --> 05:14:24,120 REACH OUT TO OTHER PEOPLE WITH 7628 05:14:24,120 --> 05:14:25,760 DISEASE HELP THEM GET 7629 05:14:25,760 --> 05:14:28,920 INFORMATION, DO ADVOCACY FOR THE 7630 05:14:28,920 --> 05:14:29,920 PARTICULAR DISEASES WITH THE 7631 05:14:29,920 --> 05:14:30,800 CONGRESS. 7632 05:14:30,800 --> 05:14:34,640 THAT IS A HUGELY IMPORTANT ROLE 7633 05:14:34,640 --> 05:14:38,800 IN GETTING MORE RESEARCH FUNDING 7634 05:14:38,800 --> 05:14:40,200 FOR THESE GROUPS. 7635 05:14:40,200 --> 05:14:42,080 FOR THESE TOPICS OF RESEARCH AND 7636 05:14:42,080 --> 05:14:45,240 DOING IT THROUGH THESE 7637 05:14:45,240 --> 05:14:47,320 FOUNDATIONS IS REALLY EFFECTIVE 7638 05:14:47,320 --> 05:14:48,000 WAY IN MOST CASES. 7639 05:14:48,000 --> 05:14:50,960 I DON'T KNOW ABOUT YOUR FEELINGS 7640 05:14:50,960 --> 05:14:51,720 ON THAT, HELENE. 7641 05:14:51,720 --> 05:14:53,600 >>WELL, YEAH. 7642 05:14:53,600 --> 05:14:58,360 WE ACTUALLY JUST STARTED OUR OWN 7643 05:14:58,360 --> 05:15:00,200 STAKEHOLDER -- WE HAD A 7644 05:15:00,200 --> 05:15:01,080 STAKEHOLDER MEETING LAST FALL 7645 05:15:01,080 --> 05:15:03,960 OPEN TO ANYBODY WHO WANTED TO 7646 05:15:03,960 --> 05:15:04,880 PARTICIPATE WHO WAS INTERESTED 7647 05:15:04,880 --> 05:15:06,560 IN WHOLE PERSON HEALTH. 7648 05:15:06,560 --> 05:15:11,520 AND SO WE HAD MEMBERS OF THE 7649 05:15:11,520 --> 05:15:14,800 PUBLIC, SOME ADVOCATES BUT ALSO 7650 05:15:14,800 --> 05:15:15,920 JUST PEOPLE INTERESTED. 7651 05:15:15,920 --> 05:15:17,640 SO HOPEFULLY WE'LL HAVE MORE OF 7652 05:15:17,640 --> 05:15:18,600 THOSE TYPES OF MEETINGS. 7653 05:15:18,600 --> 05:15:23,480 SO, YEAH. 7654 05:15:23,480 --> 05:15:23,800 7655 05:15:23,800 --> 05:15:27,480 LET'S SEE. 7656 05:15:27,480 --> 05:15:28,480 ANYTHING ELSE, ALEX? 7657 05:15:28,480 --> 05:15:31,600 >>MARCUS POSTED A QUESTION A 7658 05:15:31,600 --> 05:15:32,680 WHILE AGO, APPRECIATE YOUR 7659 05:15:32,680 --> 05:15:32,920 PATIENCE. 7660 05:15:32,920 --> 05:15:34,240 WOULD YOU LIKE TO MAYBE POSE 7661 05:15:34,240 --> 05:15:37,320 THIS QUESTION TO THE PANEL? 7662 05:15:37,320 --> 05:15:39,720 7663 05:15:39,720 --> 05:15:41,360 >>THANK YOU, ALEX. 7664 05:15:41,360 --> 05:15:43,800 I BROUGHT THIS UP BECAUSE IT'S 7665 05:15:43,800 --> 05:15:47,600 BEEN TOUCHED ON A FEW TIMES, THE 7666 05:15:47,600 --> 05:15:49,520 WHOLE IDEA OF INTERINDIVIDUAL 7667 05:15:49,520 --> 05:15:51,000 RESPONSE HETEROGENEITY. 7668 05:15:51,000 --> 05:15:52,920 WE TALKED IN THE CONTEXT OF 7669 05:15:52,920 --> 05:15:54,560 TREATMENT BUT WE DIDN'T TALK 7670 05:15:54,560 --> 05:15:57,160 ABOUT IT SO MUCH IN THE CONTEXT 7671 05:15:57,160 --> 05:15:59,480 OF DISEASE PROGRESSION, AND I 7672 05:15:59,480 --> 05:16:03,040 THINK BOTH ARE EQUALLY IMPORTANT 7673 05:16:03,040 --> 05:16:06,120 AND FRANKLY OPEN FOR SCIENTIFIC 7674 05:16:06,120 --> 05:16:06,360 DISCOVERY. 7675 05:16:06,360 --> 05:16:07,560 I THINK, YOU KNOW, THE CHALLENGE 7676 05:16:07,560 --> 05:16:09,240 THAT WE HAVE FOR THOSE WHO ARE 7677 05:16:09,240 --> 05:16:11,320 ACTUALLY INTERESTED IN THIS 7678 05:16:11,320 --> 05:16:13,600 TOPIC, WHEN WE LOOK AT DATASET, 7679 05:16:13,600 --> 05:16:15,160 WE'RE INTERESTED IN THE RANGE OF 7680 05:16:15,160 --> 05:16:16,960 THE DATA, INTERESTED IN THE 7681 05:16:16,960 --> 05:16:23,040 VARIANTS, THE PEOPLE ON THE END 7682 05:16:23,040 --> 05:16:23,800 OF THE SPECTRUM THAT DON'T 7683 05:16:23,800 --> 05:16:25,240 RESPOND AS WELL AS THOSE WHO 7684 05:16:25,240 --> 05:16:27,000 RESPOND IN A ROBUST WAY, THOSE 7685 05:16:27,000 --> 05:16:28,440 TWO EXTREMES ARE VERY 7686 05:16:28,440 --> 05:16:29,280 INTERESTING SCIENTIFICALLY AND I 7687 05:16:29,280 --> 05:16:30,640 THINK IF WE LEARN FROM BOTH OF 7688 05:16:30,640 --> 05:16:32,200 THOSE WE CAN REALLY ADVANCE THE 7689 05:16:32,200 --> 05:16:35,960 FIELD FOR THOSE IN THE MIDDLE. 7690 05:16:35,960 --> 05:16:39,960 BUT THE CHALLENGE WE HAVE AS 7691 05:16:39,960 --> 05:16:41,520 RESEARCHERS IS, YOU KNOW, 7692 05:16:41,520 --> 05:16:44,320 WHETHER IT'S FUNDING AGENCIES OR 7693 05:16:44,320 --> 05:16:46,480 WHETHER IT'S REVIEW PANELS, THE 7694 05:16:46,480 --> 05:16:50,080 FIELD AS A WHOLE CONTINUES TO BE 7695 05:16:50,080 --> 05:16:53,160 FOCUSED ON THE ME, DID YOU SEE A 7696 05:16:53,160 --> 05:16:54,680 GROUP-WIDE CHANGE, IS YOUR 7697 05:16:54,680 --> 05:16:56,960 GROUP-WIDE CHANGE DIFFERENT FROM 7698 05:16:56,960 --> 05:17:06,320 GROUP WITTED -WIDE CHANGE IN THL 7699 05:17:06,320 --> 05:17:07,320 GROUP, NON-DISEASE GROUP. 7700 05:17:07,320 --> 05:17:11,440 IF YOU WANT TO MOVE TOWARDS 7701 05:17:11,440 --> 05:17:15,960 PRECISION MEDICINE OR PRECISION 7702 05:17:15,960 --> 05:17:19,120 RE 7703 05:17:19,120 --> 05:17:20,960 REHABILITATION WE HAVE TO STUDY 7704 05:17:20,960 --> 05:17:23,680 IT WELL, I THINK THAT'S A MIND 7705 05:17:23,680 --> 05:17:25,600 SHIFT CHANGE IN SOME RESPECTS, 7706 05:17:25,600 --> 05:17:28,400 TO REALLY OPEN UP TO THIS 7707 05:17:28,400 --> 05:17:30,000 DISCOVERY OPPORTUNITY THAT 7708 05:17:30,000 --> 05:17:31,880 REQUIRES QUITE LARGE DATASETS AS 7709 05:17:31,880 --> 05:17:33,480 WELL AS INNOVATIVE METHODS TO 7710 05:17:33,480 --> 05:17:36,520 GET AT THE -- YOU KNOW, THE CORE 7711 05:17:36,520 --> 05:17:36,840 DIFFERENCES. 7712 05:17:36,840 --> 05:17:38,080 SO JUST OPEN THAT UP FOR 7713 05:17:38,080 --> 05:17:41,480 DISCUSSION. 7714 05:17:41,480 --> 05:17:44,280 >>IT'S AN EXCELLENT POINT. 7715 05:17:44,280 --> 05:17:44,920 ANYBODY HAS ANY FURTHER THOUGHTS 7716 05:17:44,920 --> 05:17:47,280 ON THIS? 7717 05:17:47,280 --> 05:17:52,320 VERY IMPORTANT. 7718 05:17:52,320 --> 05:17:59,920 THERE WAS ALSO A COMMENT, 7719 05:17:59,920 --> 05:18:01,560 SUPPLEMENTS AND DIETS, COULDN'T 7720 05:18:01,560 --> 05:18:01,840 AGREE MORE. 7721 05:18:01,840 --> 05:18:04,000 THERE'S ALSO A LOT OF NEGATIVE 7722 05:18:04,000 --> 05:18:05,480 EVIDENCE MEANING TRIALS THAT 7723 05:18:05,480 --> 05:18:06,640 SHOW THERE'S NO EFFECT AND THESE 7724 05:18:06,640 --> 05:18:07,400 ARE VERY IMPORTANT BECAUSE 7725 05:18:07,400 --> 05:18:11,240 PEOPLE SHOULD NOT BE WASTING 7726 05:18:11,240 --> 05:18:14,080 THEIR MONEY ON SUPPLEMENTS, 7727 05:18:14,080 --> 05:18:16,160 VITAMINS AND DIFFERENT 7728 05:18:16,160 --> 05:18:17,680 SUPPLEMENTS, WHEN BASICALLY 7729 05:18:17,680 --> 05:18:20,040 EATING A BALANCED, YOU KNOW, 7730 05:18:20,040 --> 05:18:22,040 DIET PROVIDES ALL THE NUTRIENTS 7731 05:18:22,040 --> 05:18:24,800 AND MINERALS, ET CETERA, THAT WE 7732 05:18:24,800 --> 05:18:25,000 NEED. 7733 05:18:25,000 --> 05:18:27,560 SO VERY IMPORTANT, YES, INDEED. 7734 05:18:27,560 --> 05:18:28,000 COULDN'T AGREE MORE. 7735 05:18:28,000 --> 05:18:31,360 >>I BRING THAT UP BECAUSE OF 7736 05:18:31,360 --> 05:18:33,680 THE GLUCOSAMINE STORY, LOOK AT 7737 05:18:33,680 --> 05:18:36,000 THE EVIDENCE, PRETTY CLEAR FROM 7738 05:18:36,000 --> 05:18:37,440 CLINICAL TRIALS AND FROM LOTS OF 7739 05:18:37,440 --> 05:18:39,720 IN VITRO STUDIES HAS NO EFFECT 7740 05:18:39,720 --> 05:18:41,480 BUT STILL A BILLION DOLLAR 7741 05:18:41,480 --> 05:18:41,760 BUSINESS. 7742 05:18:41,760 --> 05:18:43,520 >>OH MY GOODNESS. 7743 05:18:43,520 --> 05:18:46,080 SO MANY OTHER PRODUCTS THAT ARE 7744 05:18:46,080 --> 05:18:47,960 BEING SOLD THAT PEOPLE ARE 7745 05:18:47,960 --> 05:18:48,280 TAKING. 7746 05:18:48,280 --> 05:18:49,920 NOT ONLY UNNECESSARILY BUT ALSO 7747 05:18:49,920 --> 05:18:52,760 WHEN THE DOSES SOME OF THESE 7748 05:18:52,760 --> 05:18:55,720 PRODUCTS ARE SOLD AT CAN BE 7749 05:18:55,720 --> 05:18:56,800 DOWNRIGHT HARMFUL, SOME OF 7750 05:18:56,800 --> 05:18:57,320 THESE. 7751 05:18:57,320 --> 05:19:01,560 SO IT'S VERY IMPORTANT THAT WE 7752 05:19:01,560 --> 05:19:03,960 AT LEAST STUDY THESE PROPERLY. 7753 05:19:03,960 --> 05:19:08,000 BECAUSE PEOPLE ARE TAKING THEM. 7754 05:19:08,000 --> 05:19:10,400 YEAH. 7755 05:19:10,400 --> 05:19:10,640 7756 05:19:10,640 --> 05:19:16,000 >>I HAD A COMMENT ON WHAT DR. 7757 05:19:16,000 --> 05:19:18,040 BOWMAN SAID ABOUT ADDRESSING 7758 05:19:18,040 --> 05:19:18,760 INTERINDIVIDUAL VARIABILITY. 7759 05:19:18,760 --> 05:19:22,760 I DON'T THINK THAT THE WAY 7760 05:19:22,760 --> 05:19:24,360 FORWARD IS TAKE INTO ACCOUNT 7761 05:19:24,360 --> 05:19:27,440 THAT EVERY PATIENT HAS A MIX OF 7762 05:19:27,440 --> 05:19:30,160 THE RISK FACTORS, AND THAT IF 7763 05:19:30,160 --> 05:19:32,520 WE, YOU KNOW, I KEEP GOING BACK 7764 05:19:32,520 --> 05:19:35,400 TO DR. MESSIER'S WORK WHERE HE 7765 05:19:35,400 --> 05:19:38,520 SHOWED THAT, YOU KNOW, IF A 7766 05:19:38,520 --> 05:19:41,440 PATIENT IS OBESE THEN CLEARLY 7767 05:19:41,440 --> 05:19:45,400 OBESITY LEADS TO A CERTAIN 7768 05:19:45,400 --> 05:19:46,480 DEGREE OF INFLAMMATION, AND SO 7769 05:19:46,480 --> 05:19:48,160 REDUCING FAT CONTENT WILL MAKE 7770 05:19:48,160 --> 05:19:49,640 THE BIGGEST DIFFERENCE. 7771 05:19:49,640 --> 05:19:53,520 WE ALSO KNOW THAT EXERCISE IS 7772 05:19:53,520 --> 05:19:56,000 ANTI-INFLAMMATORY BUT IF YOU 7773 05:19:56,000 --> 05:19:57,880 EXERCISE TOO MUCH YOU CAN CAUSE 7774 05:19:57,880 --> 05:19:58,160 INJURY. 7775 05:19:58,160 --> 05:20:02,280 AND THAT INJURY COULD LEAD TO 7776 05:20:02,280 --> 05:20:03,760 INFLAMMATION, REPAIR MECHANISMS 7777 05:20:03,760 --> 05:20:05,320 AS WELL. 7778 05:20:05,320 --> 05:20:10,560 SO THIS WHOLE IDEA OF TAKING ALL 7779 05:20:10,560 --> 05:20:13,560 THESE VARIOUS COMPONENTS INTO 7780 05:20:13,560 --> 05:20:16,200 CONSIDERATION REALLY CALLS FOR 7781 05:20:16,200 --> 05:20:18,880 THESE SINGLE PERSON OR PRECISION 7782 05:20:18,880 --> 05:20:21,040 TRIALS WHICH MIGHT BE ANOTHER 7783 05:20:21,040 --> 05:20:23,920 DESIGN THAT WE NEED TO EMBRACE 7784 05:20:23,920 --> 05:20:29,400 WHERE, YOU KNOW, AN N-of-1 7785 05:20:29,400 --> 05:20:33,000 MIGHT STILL BE IN THE WHOLE 7786 05:20:33,000 --> 05:20:34,680 STUDY BUT N-of-1 STUDY, HOW 7787 05:20:34,680 --> 05:20:39,560 DO WE DO THOSE? 7788 05:20:39,560 --> 05:20:39,680 7789 05:20:39,680 --> 05:20:40,720 >>STEVE, ARE YOU WANTING TO 7790 05:20:40,720 --> 05:20:46,360 ANSWER OR DO YOU HAVE A 7791 05:20:46,360 --> 05:20:46,800 DIFFERENT QUESTION? 7792 05:20:46,800 --> 05:20:48,920 >>I WAS GOING TO SUGGEST FOR 7793 05:20:48,920 --> 05:20:54,840 MARCAS, HOW DO YOU STUDY THE 7794 05:20:54,840 --> 05:20:55,120 OUTLIERS? 7795 05:20:55,120 --> 05:20:58,400 WHICH IS A GREAT QUESTION, 7796 05:20:58,400 --> 05:20:58,680 MARCAS. 7797 05:20:58,680 --> 05:21:01,040 MAYBE THIS IS JUST OFF THE TOP 7798 05:21:01,040 --> 05:21:03,040 OF MY HEAD, MAYBE YOU DO THE 7799 05:21:03,040 --> 05:21:04,680 TRADITIONAL THING FOR THE 7800 05:21:04,680 --> 05:21:07,640 PRIMARY OUTCOME BUT THEN WITHIN 7801 05:21:07,640 --> 05:21:09,680 THE SAME STUDY YOU HAVE 7802 05:21:09,680 --> 05:21:13,040 SECONDARY OUTCOMES WHERE YOU 7803 05:21:13,040 --> 05:21:15,280 LOOK AT THE OUTLIERS. 7804 05:21:15,280 --> 05:21:19,480 SO YOU DON'T BECOME TOO MUCH OF 7805 05:21:19,480 --> 05:21:21,000 A REBEL, JUST HALF OF A REBEL. 7806 05:21:21,000 --> 05:21:24,280 >>I AGREE WITH YOU. 7807 05:21:24,280 --> 05:21:26,280 I AGREE WITH YOU AND THINK SOME 7808 05:21:26,280 --> 05:21:27,400 OF THE WORK THAT WE'VE BEEN 7809 05:21:27,400 --> 05:21:29,360 DOING ADDRESSING IT IN JUST THE 7810 05:21:29,360 --> 05:21:30,400 WAY YOU JUST DESCRIBED. 7811 05:21:30,400 --> 05:21:32,360 I THINK THOUGH AS A COMMUNITY WE 7812 05:21:32,360 --> 05:21:34,880 NEED TO BE THINKING ABOUT TO 7813 05:21:34,880 --> 05:21:36,640 REALLY UNDERSTAND THIS, THIS 7814 05:21:36,640 --> 05:21:38,120 REQUIRES MORE THAN YOUR SAMPLE 7815 05:21:38,120 --> 05:21:42,160 SIZE CALCULATION FOR YOUR RCT. 7816 05:21:42,160 --> 05:21:44,360 SO THAT'S THE HURDLE, RIGHT? 7817 05:21:44,360 --> 05:21:48,840 HOW DO WE GO FROM ANSWERING THE 7818 05:21:48,840 --> 05:21:51,440 PRIMARY QUESTION TO EMBRACING 7819 05:21:51,440 --> 05:21:54,040 THIS VARIABILITY THAT WE CAN 7820 05:21:54,040 --> 05:21:56,000 THEN LEVERAGE TO REALLY GO AT 7821 05:21:56,000 --> 05:21:59,560 THIS WHOLE IDEA OF PRECISION 7822 05:21:59,560 --> 05:22:00,960 MEDICINE OR PRECISION 7823 05:22:00,960 --> 05:22:01,320 REHABILITATION. 7824 05:22:01,320 --> 05:22:02,520 I MEAN, IT'S A TALL TASK, 7825 05:22:02,520 --> 05:22:03,600 REQUIRES A LOT OF DATA. 7826 05:22:03,600 --> 05:22:05,520 WE'VE GOT TO FIGURE OUT HOW TO 7827 05:22:05,520 --> 05:22:06,120 GET THERE. 7828 05:22:06,120 --> 05:22:11,520 YOU KNOW, A LOT OF THE DATA YOU 7829 05:22:11,520 --> 05:22:13,600 PRESENTED, YOU'VE DONE A 7830 05:22:13,600 --> 05:22:15,200 FABULOUS LONG-TERM WORK, YOU 7831 05:22:15,200 --> 05:22:15,960 PROBABLY ALREADY LOOKED BUT IF 7832 05:22:15,960 --> 05:22:22,120 YOU LOOK AT DATA ON WEIGHT 7833 05:22:22,120 --> 05:22:22,640 REBOUND, SOME PEOPLE 7834 05:22:22,640 --> 05:22:23,560 SUCCESSFULLY MAINTAIN THE LOSS, 7835 05:22:23,560 --> 05:22:25,520 SOME PEOPLE MAY HAVE REGAINED 7836 05:22:25,520 --> 05:22:30,000 ALL THE WEIGHT, MAYBE SOME WENT 7837 05:22:30,000 --> 05:22:34,000 HIGHER THAN WHERE THEY ENDED THE 7838 05:22:34,000 --> 05:22:40,720 TRIAL, WHAT MADE THEM DIFFERENT 7839 05:22:40,720 --> 05:22:42,280 IN THREE YEARS OF FOLLOW-UP, A 7840 05:22:42,280 --> 05:22:46,680 LOT TO BE DONE. 7841 05:22:46,680 --> 05:22:47,000 >>ABSOLUTELY. 7842 05:22:47,000 --> 05:22:51,960 KELSEY HAS A COMMENT ABOUT THE 7843 05:22:51,960 --> 05:22:52,800 REBOUND BIOLOGY? 7844 05:22:52,800 --> 05:22:54,880 >>I WAS CHIMING IN, COMMENTING 7845 05:22:54,880 --> 05:22:57,680 TOO MUCH, REALLY EXCITED ABOUT 7846 05:22:57,680 --> 05:23:00,000 THIS TOPIC, LISTENING TO WHAT 7847 05:23:00,000 --> 05:23:03,920 DR. MESSIER SAYS, HIS COHORT AND 7848 05:23:03,920 --> 05:23:14,440 OTHERS LIKE THE BIGGEST LOSER 7849 05:23:17,600 --> 05:23:18,160 COHORT, METABOLIC DYSREGULATION 7850 05:23:18,160 --> 05:23:20,680 PERSISTS, IF THE REMAINING FAT 7851 05:23:20,680 --> 05:23:22,640 IS DYSREGULATED IN A WAY WE 7852 05:23:22,640 --> 05:23:23,560 DON'T TOTALLY UNDERSTAND WHAT 7853 05:23:23,560 --> 05:23:24,960 DOES THAT MEAN? 7854 05:23:24,960 --> 05:23:26,040 THE WAY WE'RE THINKING ABOUT 7855 05:23:26,040 --> 05:23:28,600 THESE PROBLEMS? 7856 05:23:28,600 --> 05:23:32,440 7857 05:23:32,440 --> 05:23:34,840 >>I WANT TO FOLLOW UP ON WHAT 7858 05:23:34,840 --> 05:23:37,960 KELSEY SAID, SO TRUE BECAUSE 7859 05:23:37,960 --> 05:23:41,240 THERE ARE MULTIPLE MECHANISMS OF 7860 05:23:41,240 --> 05:23:41,680 EITHER REPROGRAMMING 7861 05:23:41,680 --> 05:23:43,400 EPIGENETICALLY YOUR CELLS SO YOU 7862 05:23:43,400 --> 05:23:46,280 LOSE WEIGHT BUT EVERYTHING'S 7863 05:23:46,280 --> 05:23:47,760 BEEN MODIFIED AND REALLY GROWING 7864 05:23:47,760 --> 05:23:51,080 EVIDENCE THAT THOSE CHANGES CAN 7865 05:23:51,080 --> 05:23:51,880 BE TRANSMITTED 7866 05:23:51,880 --> 05:23:52,400 INTERGENERATIONALLY, THE 7867 05:23:52,400 --> 05:23:53,160 EPIGENETIC CHANGES. 7868 05:23:53,160 --> 05:23:56,840 SO NOT CHANGING YOUR DNA 7869 05:23:56,840 --> 05:23:57,480 SEQUENCE BUT EPIGENETIC CHANGES 7870 05:23:57,480 --> 05:23:59,960 THAT PREDISPOSE YOU TO FURTHER 7871 05:23:59,960 --> 05:24:02,120 OBESITY OR OSTEOARTHRITIS CAN GO 7872 05:24:02,120 --> 05:24:02,880 DOWN AT LEAST TWO GENERATIONS, 7873 05:24:02,880 --> 05:24:04,640 EVEN IF YOU'RE ON A NORMAL DIET 7874 05:24:04,640 --> 05:24:05,520 AFTER THAT. 7875 05:24:05,520 --> 05:24:07,600 SO THESE ARE FACTORS WE DON'T 7876 05:24:07,600 --> 05:24:11,920 THINK ABOUT, WHAT DID YOUR 7877 05:24:11,920 --> 05:24:14,240 GRANDPARENTS EAT CAN AFFECT YOUR 7878 05:24:14,240 --> 05:24:16,800 HEALTH RISK BROADLY AND NOW 7879 05:24:16,800 --> 05:24:18,280 EVIDENCE IT CAN AFFECT YOUR 7880 05:24:18,280 --> 05:24:20,840 ARTHRITIS RISK, HOW DO WE ERASE 7881 05:24:20,840 --> 05:24:25,080 AND RESET THE EPIGENETIC CLOCK, 7882 05:24:25,080 --> 05:24:26,360 REMOVE THE IMMUNE DYSFUNCTION 7883 05:24:26,360 --> 05:24:28,320 THAT YOU'VE PUT INTO YOUR SYSTEM 7884 05:24:28,320 --> 05:24:31,360 BY BEING OVERWEIGHT FOR HALF A 7885 05:24:31,360 --> 05:24:33,640 LIFETIME OR EVEN UP TO 7886 05:24:33,640 --> 05:24:34,760 ADOLESCENCE, IT'S HARD TO 7887 05:24:34,760 --> 05:24:37,360 DEPROGRAM IF YOU'RE OBESE IN 7888 05:24:37,360 --> 05:24:38,880 YOUR ADOLESCENT YEARS, VERY HARD 7889 05:24:38,880 --> 05:24:40,760 TO DEPROGRAM YOUR CELLS AND YOUR 7890 05:24:40,760 --> 05:24:42,400 IMMUNE SYSTEM FROM THAT. 7891 05:24:42,400 --> 05:24:44,680 SO THESE ARE THINGS THAT WILL 7892 05:24:44,680 --> 05:24:46,000 CARRY ON, TIES INTO WHAT DR. 7893 05:24:46,000 --> 05:24:47,640 MESSIER SAID AND WHAT WE'VE SEEN 7894 05:24:47,640 --> 05:24:49,960 IN THESE STUDIES, YOU LOSE 7895 05:24:49,960 --> 05:24:52,640 WEIGHT, MAY NOT STICK BECAUSE 7896 05:24:52,640 --> 05:24:55,080 YOU HAVE PROPENSITY TO GAIN IT 7897 05:24:55,080 --> 05:24:57,600 BACK BUT AS KELSEY SAID MAY HAVE 7898 05:24:57,600 --> 05:24:58,680 ADDITIONAL IMMUNE DYSFUNCTION 7899 05:24:58,680 --> 05:25:03,960 EVEN WITHOUT THE WEIGHT. 7900 05:25:03,960 --> 05:25:05,680 7901 05:25:05,680 --> 05:25:07,720 >>ONE MORE COMMENT AND WE'LL 7902 05:25:07,720 --> 05:25:10,400 HAVE TO TRANSITION SOON. 7903 05:25:10,400 --> 05:25:10,640 MARCAS? 7904 05:25:10,640 --> 05:25:14,040 >>I THINK IT'S A REALLY 7905 05:25:14,040 --> 05:25:15,800 IMPORTANT TOPIC, ALSO 7906 05:25:15,800 --> 05:25:16,440 TRANSGENERATIONAL BENEFITS THAT 7907 05:25:16,440 --> 05:25:19,880 CARRY OVER FROM THINGS LIKE 7908 05:25:19,880 --> 05:25:22,080 EXERCISE TRAINING AND SO THAT'S 7909 05:25:22,080 --> 05:25:25,400 A WHOLE AREA OF INTERESTING 7910 05:25:25,400 --> 05:25:26,360 BIOLOGY, EPIGENETIC 7911 05:25:26,360 --> 05:25:27,280 MODIFICATIONS, ASSOCIATED WITH 7912 05:25:27,280 --> 05:25:28,880 ANY BEHAVIOR THAT CONTINUE TO 7913 05:25:28,880 --> 05:25:30,880 THE NEXT, YOU KNOW, OFFSPRING, 7914 05:25:30,880 --> 05:25:31,960 TWO TO THREE GENERATIONS DOWN 7915 05:25:31,960 --> 05:25:34,680 THE LINE, SOME NEW DATA AND 7916 05:25:34,680 --> 05:25:37,760 EXERCISE SHOWING NOT ONLY 7917 05:25:37,760 --> 05:25:39,760 MATERNAL BUT ALSO PATERNAL 7918 05:25:39,760 --> 05:25:41,960 EPIGENETIC MODIFICATIONS IN 7919 05:25:41,960 --> 05:25:43,560 EXERCISING ANIMALS AND SO THAT'S 7920 05:25:43,560 --> 05:25:44,200 DEFINITELY SOMETHING THAT NEEDS 7921 05:25:44,200 --> 05:25:46,000 TO BE CONSIDERED AS WELL. 7922 05:25:46,000 --> 05:25:48,720 >>THAT'S THE OPTIMISTIC SIDE OF 7923 05:25:48,720 --> 05:25:49,400 THINGS, RIGHT? 7924 05:25:49,400 --> 05:25:49,600 >>YEAH. 7925 05:25:49,600 --> 05:25:51,200 >>RIGHT IN BECAUSE -- RIGHT. 7926 05:25:51,200 --> 05:25:56,040 WHAT WE TRANSMIT TO OUR 7927 05:25:56,040 --> 05:25:56,920 OFFSPRING MIGHT BE SORT OF, YOU 7928 05:25:56,920 --> 05:26:01,640 KNOW, NEGATIVE BUT ALSO COULD BE 7929 05:26:01,640 --> 05:26:01,880 POSITIVE. 7930 05:26:01,880 --> 05:26:05,040 PERHAPS THE BALANCE BETWEEN THE 7931 05:26:05,040 --> 05:26:05,880 TWO, YOU KNOW, THERE'S SOME 7932 05:26:05,880 --> 05:26:08,520 THINGS YOU CAN'T DO ANYTHING 7933 05:26:08,520 --> 05:26:08,720 ABOUT. 7934 05:26:08,720 --> 05:26:09,400 BUT BEHAVIOR CHANGES IS 7935 05:26:09,400 --> 05:26:11,520 SOMETHING YOU CAN DO SOMETHING 7936 05:26:11,520 --> 05:26:14,360 ABOUT. 7937 05:26:14,360 --> 05:26:16,200 SO I JUST WANTED TO POINT OUT 7938 05:26:16,200 --> 05:26:19,160 THAT MANY OF THE ISSUES THAT WE 7939 05:26:19,160 --> 05:26:20,640 DISCUSSED IN TERMS OF CLINICAL 7940 05:26:20,640 --> 05:26:25,600 TRIAL DESIGN, ESPECIALLY WITH 7941 05:26:25,600 --> 05:26:27,480 REGARD TO MULTI-COMPONENT 7942 05:26:27,480 --> 05:26:28,840 INTERVENTIONS AND MULTI-SYSTEM 7943 05:26:28,840 --> 05:26:30,560 OUTCOMES, WE DISCUSSED AT A VERY 7944 05:26:30,560 --> 05:26:33,440 INTERESTING WORKSHOP THAT WE HAD 7945 05:26:33,440 --> 05:26:39,320 TWO YEARS AGO ON WHOLE PERSON 7946 05:26:39,320 --> 05:26:41,120 RESEARCH, AND JUST LIKE THIS 7947 05:26:41,120 --> 05:26:42,120 WORKSHOP IS VIDEO RECORDING, 7948 05:26:42,120 --> 05:26:43,640 RECORDING AVAILABLE ON OUR 7949 05:26:43,640 --> 05:26:46,920 WEBSITE, THE WHOLE PERSON 7950 05:26:46,920 --> 05:26:48,400 RESEARCH WORKSHOP IS AVAILABLE 7951 05:26:48,400 --> 05:26:50,400 AND WE'VE HAD A LOT OF PEOPLE 7952 05:26:50,400 --> 05:26:53,720 VIEW IT, AND IT REALLY DELVED 7953 05:26:53,720 --> 05:26:56,000 INTO THE COMPLEXITY OF DESIGNING 7954 05:26:56,000 --> 05:26:58,400 TRIALS THAT ARE NOT JUST ONE 7955 05:26:58,400 --> 05:27:03,240 DRUG, ONE MOLECULE. 7956 05:27:03,240 --> 05:27:07,960 SO ANYWAY, I GUESS I WANT TO 7957 05:27:07,960 --> 05:27:10,000 THANK EVERYBODY FOR THIS 7958 05:27:10,000 --> 05:27:11,960 WONDERFUL DISCUSSION AND SUCH A 7959 05:27:11,960 --> 05:27:14,360 WONDERFUL EXCELLENT ARRAY OF 7960 05:27:14,360 --> 05:27:15,960 PRESENTERS. 7961 05:27:15,960 --> 05:27:16,920 THANK YOU, CATHERINE, FOR 7962 05:27:16,920 --> 05:27:21,920 PUTTING THE LINK IN THE KTLA -- 7963 05:27:21,920 --> 05:27:23,680 CHAT AND I WILL LET ALEX WRAP UP 7964 05:27:23,680 --> 05:27:25,080 AND SEND US ON OUR WAY. 7965 05:27:25,080 --> 05:27:28,080 >>CAN I TAKE A MOMENT BEFORE 7966 05:27:28,080 --> 05:27:30,240 YOU CLOSE OUT TO SAY HOW 7967 05:27:30,240 --> 05:27:31,880 FANTASTIC THIS HAS BEEN. 7968 05:27:31,880 --> 05:27:36,680 I WANT TO THANK ALEX AND 7969 05:27:36,680 --> 05:27:37,640 CATHERINE, THE ENTIRE TEAM. 7970 05:27:37,640 --> 05:27:41,280 IT WAS A CROSS-NIH TEAM WHO PUT 7971 05:27:41,280 --> 05:27:42,920 THIS TOGETHER BUT IT'S BEEN MUCH 7972 05:27:42,920 --> 05:27:44,480 MORE THAN ONE WOULD HAVE EVER 7973 05:27:44,480 --> 05:27:45,040 EXPECTED. 7974 05:27:45,040 --> 05:27:47,200 SO THANK YOU ALL FOR ALL YOUR 7975 05:27:47,200 --> 05:27:47,720 EFFORTS. 7976 05:27:47,720 --> 05:27:49,320 THANKS TO ALL THE PRESENTERS 7977 05:27:49,320 --> 05:27:52,520 WHICH I KNOW CATHERINE IS GOING 7978 05:27:52,520 --> 05:27:52,760 TO SAY. 7979 05:27:52,760 --> 05:27:57,280 >>THANK YOU, DR. LESTER AND DR. 7980 05:27:57,280 --> 05:27:59,240 LANGEVIN FOR A WONDERFUL JOB OF 7981 05:27:59,240 --> 05:28:04,000 SUMMARIZING, WHAT YOU HEARD, 7982 05:28:04,000 --> 05:28:05,280 WHAT YOU ARE EXCITED TO SEE, 7983 05:28:05,280 --> 05:28:07,960 GAPS, THANK YOU BOTH FOR A 7984 05:28:07,960 --> 05:28:09,360 WONDERFUL SESSION 6 AND GENERAL 7985 05:28:09,360 --> 05:28:11,040 DISCUSSION TO BRING US NOW TO 7986 05:28:11,040 --> 05:28:17,520 TURNING THINGS OVER TO DR. ALEX 7987 05:28:17,520 --> 05:28:19,680 TUTTLE, PROGRAM DIRECT GALORE 7988 05:28:19,680 --> 05:28:20,720 NCCH DIVISION OF EXTRAMURAL 7989 05:28:20,720 --> 05:28:22,680 RESEARCH, TO BRING OUR WHOLE 7990 05:28:22,680 --> 05:28:25,920 JOINT HEALTH WORKSHOP TO A CLOSE 7991 05:28:25,920 --> 05:28:28,760 WITH CONCLUDING REMARKS. 7992 05:28:28,760 --> 05:28:31,840 ALEX, I'M TURNING IT OVER TO 7993 05:28:31,840 --> 05:28:32,720 YOU. 7994 05:28:32,720 --> 05:28:33,040 PLEASE UNMEET. 7995 05:28:33,040 --> 05:28:34,360 >>I GOT THE MUTE. 7996 05:28:34,360 --> 05:28:36,040 THANK YOU VERY MUCH FOR THE 7997 05:28:36,040 --> 05:28:37,280 INTRODUCTION AND THANK YOU FOR 7998 05:28:37,280 --> 05:28:39,480 ALL MODERATION OVER THE PAST TWO 7999 05:28:39,480 --> 05:28:40,080 DAYS. 8000 05:28:40,080 --> 05:28:41,240 IT WAS SEAMLESS AND I THINK WE 8001 05:28:41,240 --> 05:28:44,640 HAD A LOT OF GREAT DISCUSSIONS. 8002 05:28:44,640 --> 05:28:45,640 GREAT SCIENTIFIC TALKS. 8003 05:28:45,640 --> 05:28:47,800 A LOT TO THINK ABOUT. 8004 05:28:47,800 --> 05:28:49,160 RATHER THAN REHASHING WHAT WE'VE 8005 05:28:49,160 --> 05:28:52,800 JUST BEEN DISCUSSING IN TERMS OF 8006 05:28:52,800 --> 05:28:58,560 TAKEHOME MESSAGES AND HIGH 8007 05:28:58,560 --> 05:28:59,520 PRIORITY OR MUCH-DISCUSSED 8008 05:28:59,520 --> 05:29:01,960 TOPICS I'LL THANK EVERYONE WHO 8009 05:29:01,960 --> 05:29:05,280 MADE THIS WORKSHOP POSSIBLE. 8010 05:29:05,280 --> 05:29:08,000 NIH SPEAKERS, DR. REBECCA BAKER 8011 05:29:08,000 --> 05:29:11,480 FOR SETTING ETHICS OFF, DR. 8012 05:29:11,480 --> 05:29:14,640 LANGEVIN FOR OPENING COMMENTS 8013 05:29:14,640 --> 05:29:17,520 AND, DR. CRISWELL WHO ALSO 8014 05:29:17,520 --> 05:29:21,000 PROVIDED OPENING COMMENTS AND 8015 05:29:21,000 --> 05:29:23,200 DR. EMMELINE EDWARDS, FOR 8016 05:29:23,200 --> 05:29:24,320 PROVIDING CLOSING COMMENTS 8017 05:29:24,320 --> 05:29:24,920 YESTERDAY. 8018 05:29:24,920 --> 05:29:27,120 I THANK DR. KOROSHETZ, NINDS 8019 05:29:27,120 --> 05:29:29,160 DIRECTOR, FOR OPENING DAY 2 THIS 8020 05:29:29,160 --> 05:29:32,320 MORNING AND DR. LESTER FOR HER 8021 05:29:32,320 --> 05:29:33,960 PARTICIPATION AND MODERATION OF 8022 05:29:33,960 --> 05:29:34,240 SESSION 6. 8023 05:29:34,240 --> 05:29:37,120 THANK YOU TO ALL OF OUR NIH 8024 05:29:37,120 --> 05:29:37,560 LEADERS. 8025 05:29:37,560 --> 05:29:41,520 I WANT TO THANK THE SCIENTIFIC 8026 05:29:41,520 --> 05:29:42,280 PLANNING COMMITTEE MEMBERS. 8027 05:29:42,280 --> 05:29:44,400 THIS WAS A VERY LARGE EFFORT 8028 05:29:44,400 --> 05:29:46,600 ACROSS SEVEN I.C.s INTERESTED 8029 05:29:46,600 --> 05:29:47,880 IN THIS TOPIC. 8030 05:29:47,880 --> 05:29:50,360 IN PARTICULAR I WANT TO THANK 8031 05:29:50,360 --> 05:29:52,640 DR. WEN CHEN WHO HELPED ME 8032 05:29:52,640 --> 05:29:54,080 DEVELOPED THE PROGRAM INITIALLY 8033 05:29:54,080 --> 05:29:56,160 AND PRESENTED TO OTHER 8034 05:29:56,160 --> 05:29:59,080 INSTITUTES AND CHAIRS AND 8035 05:29:59,080 --> 05:30:02,120 CO-CHAIRS ACROSS THE NIH WHO 8036 05:30:02,120 --> 05:30:05,640 REALLY HELPED TO DEVELOPED 8037 05:30:05,640 --> 05:30:06,760 PROGRAMS, SELECT SPEAKERS, 8038 05:30:06,760 --> 05:30:12,400 EXTERNAL CO-CHAIRS, , SET THE 8039 05:30:12,400 --> 05:30:14,040 PROGRAM, NOT POSSIBLE WITHOUT 8040 05:30:14,040 --> 05:30:14,640 DEDICATED MEMBERS SUPPORTING 8041 05:30:14,640 --> 05:30:15,440 THIS EFFORT. 8042 05:30:15,440 --> 05:30:19,360 LAST BUT NOT LEAST I WANT TO 8043 05:30:19,360 --> 05:30:21,160 THANK THE NCCIH LOGISTICS TEAM, 8044 05:30:21,160 --> 05:30:22,520 THIS INVOLVES PEOPLE IN THE 8045 05:30:22,520 --> 05:30:26,040 DIVISION OF EXTRAMURAL RESEARCH 8046 05:30:26,040 --> 05:30:32,960 WHO WORK WITH ME, OUR ANALYST, 8047 05:30:32,960 --> 05:30:35,960 OUR BRANCH CHIEF, ANITA WHO 8048 05:30:35,960 --> 05:30:38,720 PROVIDED OUTREACH SUPPORT AND 8049 05:30:38,720 --> 05:30:40,720 EMMELINE EDWARDS TO HELP APPROVE 8050 05:30:40,720 --> 05:30:41,720 THE PROGRAM AND CIRCULATE ALL OF 8051 05:30:41,720 --> 05:30:44,200 THE MATERIALS AS WELL AS OFFICE 8052 05:30:44,200 --> 05:30:46,800 OF COMMUNICATIONS STAFF, 8053 05:30:46,800 --> 05:30:48,560 CATHERINE LAW, DIRECTOR, WHO 8054 05:30:48,560 --> 05:30:52,800 MODERATED, LED HER TEAM DOING A 8055 05:30:52,800 --> 05:30:55,640 GREAT JOB, IRENE LIU, AILEEN 8056 05:30:55,640 --> 05:30:59,040 AMADOR, SUPPORT WITH MODERATING 8057 05:30:59,040 --> 05:31:01,200 QUESTIONS, AND BRYAN WHO 8058 05:31:01,200 --> 05:31:03,360 PROVIDED ALL THE MATERIALS, 8059 05:31:03,360 --> 05:31:06,560 BACKDROPS OVER THE PAST TWO 8060 05:31:06,560 --> 05:31:06,800 DAYS. 8061 05:31:06,800 --> 05:31:08,360 THANKS TO SOPHIA AND TEAM FOR 8062 05:31:08,360 --> 05:31:09,720 PUTTING TOGETHER PROGRAM BOOK 8063 05:31:09,720 --> 05:31:14,600 AND FINAL A AGENDA. 8064 05:31:14,600 --> 05:31:20,800 THIS IS THE REAL LAST, THANK YOU 8065 05:31:20,800 --> 05:31:23,400 TO EVERYONE WHO PROVIDED 8066 05:31:23,400 --> 05:31:25,600 SCIENTIFIC TALKS, PARTICIPATED 8067 05:31:25,600 --> 05:31:27,640 AS PANELISTS, MEMBERS WHO SIGNED 8068 05:31:27,640 --> 05:31:29,560 ON AND PARTICIPATED WITH US OVER 8069 05:31:29,560 --> 05:31:34,040 THE PAST TWO DAYS. 8070 05:31:34,040 --> 05:31:35,320 YOUR VIEWERSHIP AND QUESTIONS 8071 05:31:35,320 --> 05:31:39,480 WERE A LARGE PART AND GAVE US A 8072 05:31:39,480 --> 05:31:41,160 LOT TO THINK ABOUT. 8073 05:31:41,160 --> 05:31:43,680 THANK YOU FOR YOUR PARTICIPATION 8074 05:31:43,680 --> 05:31:44,760 AND CONTRIBUTIONS, I'LL TURN 8075 05:31:44,760 --> 05:31:45,600 THINGS BACK OVER TO CATHERINE 8076 05:31:45,600 --> 05:31:47,600 LAW TO TAKE US OUT. 8077 05:31:47,600 --> 05:31:48,800 >>THANK YOU SO MUCH, ALEX. 8078 05:31:48,800 --> 05:31:51,760 I HAVE A WONDERFUL TASK OF 8079 05:31:51,760 --> 05:31:53,520 REMINDING VIEWERS, I THANK THEM 8080 05:31:53,520 --> 05:31:55,280 FOR JOINING US AND SHARING 8081 05:31:55,280 --> 05:31:56,680 WONDERFUL QUESTIONS, FROM OUR 8082 05:31:56,680 --> 05:31:57,040 AUDIENCE TODAY. 8083 05:31:57,040 --> 05:31:59,520 AND NOW I'M GOING TO REMIND YOU 8084 05:31:59,520 --> 05:32:01,640 ALL WE HAVE RECORDED THIS, IT 8085 05:32:01,640 --> 05:32:03,040 WILL BE ARCHIVED FOR FUTURE 8086 05:32:03,040 --> 05:32:05,040 VIEWING, YOU CAN SHARE THIS WITH 8087 05:32:05,040 --> 05:32:07,480 COLLEAGUES AND MAKE SURE 8088 05:32:07,480 --> 05:32:09,840 EVERYBODY WATCHES IT. 8089 05:32:09,840 --> 05:32:12,400 AND WITH THAT SAID, I WANT TO 8090 05:32:12,400 --> 05:32:14,880 ALSO ECHO ALEX'S THANKS TO 8091 05:32:14,880 --> 05:32:16,800 EVERYBODY HERE TODAY, PLANNING 8092 05:32:16,800 --> 05:32:19,120 TEAM MEMBERS, AND THE WONDERFUL 8093 05:32:19,120 --> 05:32:19,920 SPEAKERS AND PANELISTS, AND I 8094 05:32:19,920 --> 05:32:21,720 THINK WE HAD A VERY RICH 8095 05:32:21,720 --> 05:32:23,560 DISCUSSION ACROSS ALL OF OUR 8096 05:32:23,560 --> 05:32:27,360 SESSIONS SO I CONGRATULATE YOU 8097 05:32:27,360 --> 05:32:28,960 ALL ON TACKLING VERY FASCINATING 8098 05:32:28,960 --> 05:32:29,200 TOPICS. 8099 05:32:29,200 --> 05:32:31,600 SO WITH THAT, I'M GOING TO BRING 8100 05:32:31,600 --> 05:32:33,440 OUR MEETING TO A FINAL CLOSE. 8101 05:32:33,440 --> 05:32:34,840 THANK YOU AND GOOD EVENING. 8102 05:32:34,840 --> 05:32:36,280 I HOPE TO SEE YOU ON ANOTHER 8103 05:32:36,280 --> 05:32:39,440 ZOOM IN THE FUTURE OR MAYBE IN 8104 05:32:39,440 --> 05:32:40,480 AN IN-PERSON MEETING EVEN. 8105 05:32:40,480 --> 05:32:41,920 WITH THAT, I WISH YOU ALL WELL . 8106 05:32:41,920 --> 05:32:42,800 HAVE A WONDERFUL EVENING. 8107 05:32:42,800 --> 05:32:43,320 THANK YOU. 8108 05:32:43,320 --> 00:00:00,000 BYE-BYE.