All right, we got 8.02 on my clock with a good amount of participants for the audience and our speakers are in. So let's get rocking. So I'm Nathan Katz, I'm a part of the AAP Medical Student Council, part of the education subcommittee. And we're excited to bring you a really good kind of program today with three really awesome speakers. We got Francesco out of the University of South Carolina. He's an MS4, so my apologies again for that, Francesco. And he'll be up first talking about the recommendations and guidance for steroid injection therapy and COVID-19 vaccine administration from the American Society of Pain and Neuroscience. So a really exciting topic. Quick housekeeping stuff, you all saw the comments from Jewel Fawcett in the chat. So just a reminder to keep mics muted as much as you can while the speaker is kind of doing his or her thing. And then, you know, our goal with these type of sessions is also to be interactive. And I've asked the speakers to try and be as interactive as possible with their presentation to kind of make this a very engaging topic with all three of their topics. So you know, at the tail end of things in between speakers, we'll have a set time for questions and answers. So feel free to come on video and ask your person, kind of Zoom face-to-face as best you can, just to create more of an engagement with our speakers and our audience. Okay. And without further ado, I'll let Francesco go ahead and take over and go ahead and present for us. Sure. Thanks very much. Let me just get this actually started here. Can everyone see the PowerPoint? Yes, we can. Sure. So my name is Francesco Malli. I'm from Columbia, South Carolina. And this is a study that was mainly a guideline kind of update study based on steroid injection therapies and how that might affect COVID vaccination, but they went into plenty of other pain type treatments. The one thing I want to start off with is just kind of getting a concept of where we are in terms of COVID-19. As you can see, we have over 30 million cases, and I think we're adding 70,000 each day now. Last week it was at 60,000. So it keeps kind of becoming a bit worse for us. We've had over half a million deaths at this point, and one of the big concerns we're starting to have is what's called a long COVID syndrome. And especially in the realm of PM&R, there have been some studies trying to see just how prevalent this is. There was an observational group study. I believe this was in Michigan. I might have that wrong, but out of the 488 patients, about 33% had persistent symptoms. And you can see the most common ones there. Of course, this doesn't kind of differentiate the severity of them. And there was an Italian study that actually showed symptoms in 87% of the people that they had discharged from the hospital. So this is starting to become a pretty prevalent illness. And here's just a graphic I found that shows some of the longer, what they call post-acute COVID and getting into the chronic stage, the different symptoms that you're going to start experiencing or could start experiencing. And you can see fatigue and weakness and joint pain, oxygen requirements, headaches. These are a lot of things that you might have to deal with in PM&R. And certainly if you have a hospitalized patient of yours that then gets COVID and then this gets added on to their list of chronic conditions, it's something that you'd rather avoid. And so the next question is, well, why do we want to focus on pain interventions in this setting? One of the big things is that they're used in a lot of different specialties for a lot of different purposes, osteoarthritis being one of the biggest ones, but also autoimmune conditions sometimes for helping with cancer symptoms and patients that are being rehabilitated for cancer. And right now, you know, we are in a global pandemic. We're struggling to reach acceptable levels of vaccination. And we really want to ensure that the treatments we're giving patients, if we're also trying to vaccinate them, aren't going to have an impact on their vaccination response or efficacy. So we'd like to understand how pain medications might or might not change our treatment plans, either for us or for another provider so that we can start practicing some team medicine. I think that kind of gets us to that goal. So I want to have some quick refreshers here, just so we're all on the same page. These are all the treatment modalities that are heavily mentioned in the paper. So cortisone shots, many of you have probably seen these in the clinic, either in the knee, shoulder, you might have done an epidural before, seen it in the wrist or carpal tunnel. And these help alleviate pain and inflammation. Systemic steroids can be prednisone, there are a lot of equivalents to that, such as dexamethasone. And some of these are an oral formula, sometimes they can be an IV. But usually, they are tapered over a set period of weeks. They can be a long term treatment plan, usually for some autoimmune conditions, in which they can have relatively high dose amount of steroids. And you'll find this is a section where we start getting into a bit of a risk benefit analysis in terms of continuing a steroid therapy versus going to vaccination or not. NSAIDs, this your over-the-counter anti-inflammatory drugs that, you know, if you remember your pharmacology from your preclinical years, have action on the COX-1 and COX-2. And then acetaminophen, this sometimes gets lumped in with NSAIDs, sometimes it's put as separately. We don't really have a great mechanism of action to find for this. It's sometimes said to act centrally only in the brain for as a pain reliever, and it's also an antipyretic. Some people say it's a weak COX-1-2 inhibitor. But the study does go over this a little bit. The mechanism isn't so important just to the fact that it is used for a lot of pain conditions. And here's just a small graphic. I think it's nice to have a concept of what the COVID vaccines actually are, just some basic background in their development and what they do inside the body. You can see the Pfizer, Moderna, and Inovio. These all use the mRNA type vaccine, which is a nucleic acid vaccine. These are the first of their kind that we've ever made before. This shows you just that you get a portion of the mRNA for the spike protein of the virus, and then the human cell translates that into a protein and then presents it to an antigen processing cell. The J&J and AstraZeneca vaccines use the adenovirus vector, and so this is the actual DNA. They basically sequence the protein and then create it into a DNA sequence, put it in an adenovirus vector, and then the cells start expressing that protein for the antibodies to attach to. If you've been keeping up, these are the two vaccines that have had issues with clotting. Not saying that that's the reason why, it just so happens to be that they're using the same mechanism. But that's just the basic background behind it. I think it's helpful to inform. Now we'll get into the study question, which is, what are the recommendations for pain management when considering COVID-19 vaccination for a patient? A bit about the study design, basically what's been done here is they've taken some of the vaccine trial data from the COVID-19 vaccines, where they did have some patients that were using pain medications, and we'll get into some of the exclusionary criteria to understand what wasn't tested for in there. Some of the previous guidelines, either from other guidelines for COVID-19 specifically or even previous vaccines like influenza, and then they also used expert recommendations. And this all kind of forms up this study of guidelines for steroid therapy. So in the vaccine trials, I thought it would be helpful to understand what they excluded. So when we talk about what their efficacy is, we know what wasn't in the trial. So we know what we have to be careful about in terms of understanding what these patients might expect in terms of responsiveness. So in most of these vaccine trials, I won't get into the details too much, but you can see they excluded immunosuppressed patients or anyone who was immunocompromised or thought to be immunocompromised or had any systemic steroid use. Most of them did not exclude any targeted steroid therapies. One of the things about Moderna specifically is they outlined anyone who was having corticosteroids of 20 milligrams a day or greater, or 20 mg per kg of prednisone or equivalent was exclusionary because they consider that to be a high dose of systemic steroids. AstraZeneca, similar exclusions. There's the Janssen vaccine, which I haven't heard too much about, but noteworthy exclusion criteria there. And Novavax had similar exclusions. And so these exclusions kind of help inform us of what a best practice might look like. So now we're going to kind of dip into the recommendations for the therapies that the paper had. So first of all, for epidural and local corticosteroids, and here are just some pictures showing some of the sites that you might see this done. Local corticosteroids, in general, you probably wouldn't think intuitively they'd have any large effect on the immune system or any large systemic effect. And that's mostly true. Probably the one area that most people were concerned about was an epidural because they are known to have some effects outside of where they're being injected. Post-procedure hyperglycemia, blood pressure elevation, cortisol reduction with specific agents. These are things that are known to happen and are looked out for as complications. But just based on the current dosing regimens, the pharmacodynamics of these medications, the authors said that it's really unlikely that there's any sort of immunosuppression effect that you would see in a chronic high-dose systemic use. And hopefully no one is day-to-day giving their patient an epidural after epidural. So you probably shouldn't be doing that anyway. Local corticosteroids, such as knee injections, shoulder injections, admittedly specific data is lacking. But retrospective analysis, there was one study of stating some increased risk in influenza of any patients who receive joint injections. The problem with the study is it had a lot of confoundment, which meant it had a lot of variables not accounted for. Most of these patients who are getting these injections, they have higher rates of autoimmune disease, diabetes or COPD, you know, and so it becomes very hard to rely on that kind of data. So just based off of what we know, not just from the epidural shots, but also from corticosteroids and how they work, they felt that the overall takeaway for this is that there's not really any evidence to support any changes to pain management plans when vaccinating for COVID if you're using a local corticosteroid. So all your interventional spine procedures, your knee injections, anything for osteoarthritis is mostly a safe bet that you're not going to change much of anything. Moving on to the systemic steroids. As I mentioned, this is where things get a little bit difficult to decide upon. And we actually have some cases that I'm hoping are a bit interactive for you guys that we'll go through. But just some quick clarifications. As I said, when we talk about high dose, that's going to mean two mgs per kg or 20 milligrams a day of prednisone or equivalent for two or more weeks. Now the or equivalent is important because if you're using something other than prednisone, like dexamethasone, you have to understand that there is a conversion for that because it's quite a bit stronger than prednisone, about three to four times. The other thing here is if there are any live vaccines that end up becoming heavily used in the USA, we'll need to update these recommendations because these aren't really being distributed in the USA right now. So they weren't really discussed in this paper. And in a virus factors such as the AstraZeneca and J&J probably are safe. There's no reason to think they wouldn't be because they're safe for immunocompromised patients anyway. So efficacy, some of the findings, these are based off studies that have been done off of previous vaccines. So there isn't really anything available for COVID-19 responsiveness in terms of systemic steroid use, but we can kind of piggyback off of previous data. So we're concerned because we know that there is an effect on antigen presentation, TRB cell function, antibody generation. We know that steroids can affect all of these things. And there are several studies that have shown decreases in efficacy from systemic steroid use. There was decreased responsiveness and protection from a pneumococcal vaccine at a high dose. Hep B vaccination in children on high dose steroid therapy for nephrotic syndrome was affected and the influence of vaccination efficacy among cancer patient on systemic steroids was affected. However, the caveat here is these effects were a bit small. I don't have the exact numbers, but overall the authors felt like that these effects didn't affect it enough to just completely say that anyone on systemic steroids, even a high dose absolutely should not be getting a vaccine. They sort of left it up to the interpretation of the clinician as to what they felt was the right move or not. Um, short-term boluses, this is a really important point. They did not have any effect. And this was seen in both trials for a tetanus and influence of vaccine studies. So if your patient is having a short-term bolus, you can be certain that it's not going to have any sort of effect on the efficacy. Also, any inhaled steroids, while they technically are systemic as well, they didn't have any effect on a hep B vaccination study. So it's a safe bet to say that any patients with asthma who use these on a regular basis aren't going to be having any issues or any of your COPD patients. So the key takeaways for systemic steroids is these need to be considered case by case and a patient needs to be educated on the risk and benefits for them personally delaying or stopping treatment for their condition is going to mean different things for different patients. Some patients are okay with stopping their medication and dealing with the consequences of their autoimmune condition flaring up for however long you need to do it in order to get vaccinated and have good efficacy. For now, because of things like that, there aren't any strict guidelines specifically for this. And the one thing to remember is the equivalent dosages for different steroids and to understand their activity. So I just put this nice chart here. It kind of shows you what I was talking about that different steroids have different actual effects, half-lives, potencies, and that becomes very relevant when you start to talk about this. So now here are some cases for us to consider. And these are all systemic steroid use vaccination, and these are all kind of a risk versus benefit analysis. So the first one is a 35-year-old patient with severe lupus that is treated with prednisone 30 mg a day, PO. And 30 mg a day is in our criteria of a high dose of systemic steroids. And so I'll kind of do this case myself the first time, but the second one, third one, maybe we can ask if someone wants to try and take it on. But basically when approaching this patient, the first thing to understand is what happens with their lupus, what are they experiencing in terms of symptoms, and how much can we really reduce that dosage before they start to say that they don't want to reduce it anymore and feel any more symptoms beyond that point. If they're not willing to go below that 30 mg per day, they say, this is where I'm happy and I feel like I'm in my best quality of life. Personally, myself as a clinician, I would just have a conversation with them about best practices for avoiding infection from COVID and how to properly mask, keep hand hygiene. But another thing to consider is because the efficacy was not affected so much by systemic steroids, we might still consider vaccinating this patient because this isn't too far from the minimum criteria for high-dose steroids. And there was a small effect seen there, so maybe it's still worth it getting a vaccination, but that's a huge conversation to have with the patient. The next one, and someone can take this, is a 67-year-old cancer patient who's taking prednisone, 20 mg PO twice a day, and this is used as something to add to their pain management. And I don't know if someone wants to volunteer or maybe talk through about this. Hi, I can try to attack it. So one thing I'm thinking about is depending on the type of cancer they have and comorbidities, how their kidney function is, bleeding risk, things like that. If you could maybe switch them to like temporarily a high dose NSAIDs, you know, Tylenol, something like that in the short term while they're vaccinated and then get them back on the steroids after or even, you know, opioids, which that's a whole different discussion, but like a short-term different management of their pain. Good, yeah, I think that's a really good idea. That's probably, I think, a lot of people would go with that, trying to just switch to another medication so we don't have to cause them any more pain. The other one on this one I thought was interesting is one of the ones with dexamethasone and then I don't want to take up too much time. So if someone wants to take the third one, which is a 49-year-old with glioblastoma, I know it's a sad case, who is suffering from cerebral edema and is being treated with dexamethasone 16 milligrams a day in order to help with this symptom. And there's the little conversion there for what equivalent that would be in prednisone. So it's fine if no one wants to volunteer, I'll just kind of go through it. So the problem here is that this is quite a severe symptom in a cancer rehab patient. And it would take understanding, you know, to what degree is the cerebral edema affecting them. And are you really able to come off of that steroid therapy what other symptoms are going to start popping up because you're treating them so heavily with the steroid. This would, in my mind, probably be a patient who is not really a great candidate to take off of steroids and get vaccinated. And so you are running a risk there with getting infected with COVID. Their immune condition is probably not great, so they would likely get severe infection. So you do everything you can to isolate them, make sure their family understands what that means in terms of visiting them and being very careful about hygiene. So it's a tricky one, and it's unfortunate because there's not much you can do to change the situation. You just have to sort of deal with the hand that the patient is given. So moving on to NSAIDs. NSAIDs and other toxin inhibitors. These are a common alternative to opioids for pain management. Aspirin, acetaminophen, ibuprofen, nomethacin, naproxen. The data so far in these, there's been some vaccine trials investigating if there's any effect, and realistically, there hasn't been seen any sort of huge effect. Acetaminophen had some antibody blunting, but the protective antibody levels were still acceptable. So from the data we have, there's really no suggestion to change anything. The caveat is there's really very little research on this, understandably. These aren't the big guns you're going to be going to with people who are in major pain. So there needs to be some more specific dosages, what frequency was being used. These studies here were good, but they were a little bit vague on that, so it would be nice to have that. So the key takeaway is the data are sort of inconclusive, insufficient, not robust enough. But for now, from what we do have, wouldn't be changing any practice algorithms or any treatment plans. So the last thing I wanted to talk about is the ethical considerations of pain management. And this particularly applies to some of the cases we are talking about. And the authors made a quick word on this specifically for interventional spine procedures, but I believe this applies to systemic steroids as well. I'll read some of the quote. The opioid epidemic in particular has grown in magnitude. And a lot of this due to restricting access to critical pain management care, as well as barriers to access to substance use disorder treatment. The literature on the impact of spinal procedures, COVID-19 vaccination is supportive of virus prophylaxis and pain management. Although you can't be 100 percent certain about the safety. Undoubtedly, patients requiring spinal procedures for pain control should be provided with education so they can provide an informed consent. And if they pursue COVID vaccination with a spine procedure, that should be absolutely allowed. And so obviously, I think the study kind of bears that out. But we'll go a little bit more into it, a sort of a point versus counterpoint here of vaccinating someone versus managing their pain. On the vaccinating side of the argument, interventional treatment is elective, especially during a severe pandemic. Especially a spine procedure, a spine pain procedure. It is an elective procedure. These medications aren't technically required for a patient to survive their illness in most cases. But on the other side, patients have a very unique experience with pain. What a clinician or a family member might consider elective, that could be incredibly vital to the patient having any sort of quality of life. It might be completely debilitating to them. In some rare cases, maybe fatal to take them off of their pain management. On the other side, you might require a vaccine in order to participate in social events or work safely. And that can impact the patient very severely if they're not able to work, if they're not able to go out. There's been talks about a COVID vaccination passport. But on the other side, the pain a patient experiences might be too severe to participate in those events anyway. So if you took them off of it and you got them vaccinated, would they realistically be able to go participate in that? And would these conditions not then be under control in the future because now you're having to play catch up with them? And some of the last points, a population that requires treatment with high dose steroids and or pain conditions are likely at high risk for a COVID-19 infection, which is largely true. A lot of these patients are elderly. They're likely going to be more likely to get infected, more likely to have severe infections, especially if they're cancer patients or autoimmune patients. However, on the other side, the risk of infection might not reach the patient's own threshold for action, as does their constant debilitating pain. So it's really this focus of, you know, what does the patient perceive as their best option for their quality of life or what they want to do? Ultimately, we would love to have herd immunity and everyone vaccinated, but it shouldn't come at the cost of the patient living the life that they want to live. And if that doesn't include the vaccination, then in my opinion, we should respect that and do everything we can to make sure they don't get infected. And these are just some summaries of the guidelines and the ethics that we went through. There's not too much else to go through here because we've sort of gone through everything. But just to reiterate, you know, there's not much to change about local injections, NSAIDs, acetaminophen, epidurals. Really, it's the systemic steroids, the high dose ones among them, that are going to be the places where you need to consider it. And you need to be keeping an eye out for on your charts for your patients. You know, does their past medical history list a chronic pain condition? If it does and you're on a rotation where you know you're trying to get them vaccinated, do you want to look into that further? Are they on a systemic steroid or a taper? And that needs to be a conversation. Just remember, though, the responsiveness effects were small and short boluses weren't affected either. So there aren't too many cases you should run into. But if you do, hopefully this presentation kind of helped you consider, you know, what your risk benefit would be and what the ethics of it are. And these are my references, if you care to go look at it. And thank you guys very much. Awesome. Thank you, Francesco. Let's take a time. I know that's a very awesome and important lecture and really presented it well. So thank you again. For the sake of time, in case someone has burning questions on that presentation or wants to kind of get in touch with Francesco, let me have you put your email or we'll take that question and answer to the chat feature just so we can get ready for our other two presenters here. Coming on up. OK. All right. So let's move right along here. So next up, we have Hyejin. All right. Good evening, everybody. First of all, thank you so much to Nathan. I don't know if you guys notice, but this is like inaugural session. So he's doing a fantastic job. So just giving a virtual shout out to Nathan. And we're going to dive right in to the world of Dan's and Parkinson's disease. So this month, April marks the Parkinson's disease, I guess, is the awareness month. And I'm going to combine that with a little bit of passion of mine, which is Dan's and performing arts medicine. And I'm going to ask you this moment to ask people to turn their cameras on because we will make this as interactive as possible. And I know you guys have beautiful faces behind the wonderful world of Zoom screen. So if you're able, we'd love to see everybody's faces. Come on. Hello. All right. So here we go. Let's dive right in. So if you have your phone, I would love for you to take it out, take a little QR screen code. Or if you don't have your phone, you can also go into Menti.com and use that code 5241013. And whatever comes to your mind when you hear dance medicine and performing arts medicine, I want you to type that in. And don't overthink this. This is not an English literature class. We're all mostly scientists here after all. So whatever comes to your mind, please submit. All right. I'm seeing them come in through. Awesome. All right. Keep those responses in. Great. Just a few more. All right. Closing in in 3, 2, 1. All right. So I'm going to share what everybody is saying here. Let me see if I can do this. All right. So the words that come to mind, it seems like escape, passion, rehabilitation, physical therapy, flexibility, yoga, movement, geriatrics. Okay. Yeah. Therapy, exercise, mobility and theater. All right. Great. So these are all wonderful, wonderful contributions. So with that in mind, let's kind of delve into what performing arts medicine and also just to make it a little bit personal. I do have personal pictures scattered throughout. So enjoy. All right. So we have performing arts medicine. That is a branch of occupational medicine that formally addresses the medical concern of those who are artists, you know, play instrument, musicians, sing or dance. But I want to clarify that anybody who has the ability or passion or the thrill to just move your bodies, you are a dancer. So if you can even just do this right now, you are a dancer. So welcome to the world of dance. All right. And then that covers overall health prevention and management of injuries related to artists of all types as they practice their craft. So dance medicine is actually a subset of performing arts medicine and that investigates the cause of dance injuries, promotes their care, prevention. And as somebody said earlier on, save post rehab, return to dance and explores the how of dance movement. So this is what dance medicine, performing arts medicine is. But taking that kind of idea forward. Now, take your phone out again and take a little screenshot of this. And now we're going to talk a little bit about what are some motor and non-motor symptoms of Parkinson's disease. So whatever comes to mind, just type that in for me. Awesome. Responses are rolling in. I keep them coming. Great. Just a few more. All right. Awesome. Thanks for your participation, everybody. All right. Closing in in three, two, one. Oh, great. OK, so here are the results. The audience has spoken. All right. So loss of arm swing, depression, bradykinesia, shuffling, weakness, slowing, rigidity, pain, tremor, cogwheel rigidity, which is classic, tremors, cogwheel rigidity again, resting tremor. Awesome. So thank you so much to all for participating and giving the good thoughts rolling. Because now we got to take these ideas that we have all kind of contributed and talk a little bit about the motor skill and the non-motor skill symptoms of Parkinson's. So I think most of us here just talked about the cogwheel rigidity portion of Parkinson's. But we also see some vocal symptoms and bradykinesia and tremors and classic shuffling gait or the walking disability or difficulties. But what's often overlooked, too, is the non-motor skills. So non-motor skill symptoms includes cognitive, psychological, sleep, even autonomic and sensory impairment. And this feature significantly in clinical picture of advanced Parkinson's disease. So it could often be overlooked or unrecognized by clinicians and remain untreated. And consequently, that could contribute to severe disability and impairment and even shorten the lifespan and expectancy. So taking that idea forward of dance and movement and how Parkinson's disease is that impairment of movement, dance is actually emerging as an effective intervention for range of symptoms in Parkinson's disease. And not surprisingly, we're talking about some motor things here, including gait, balance and coordination. And so dance for Parkinson's disease is actually born from this idea that people with Parkinson's disease could benefit from the incident specific techniques and methods used by dancers to guide their own bodies and mind. And there's this very famous dance company called the Mark Morris Dance Group. And they kind of are creating this dance for Parkinson's disease. And let's take a look at what a class looks like. All right. Palms together on four. Elbows widening, hands sliding down, eyes lowering. So we can kind of see that it is really playing on a broad dance styles, ranging from ballet, folk dance, improvisation to even modern. All right. Look how cute these people are. So cute. All right. So that being said, we are going to kind of take these ideas forward. And while dance may improve motor features in Parkinson's disease, it is not really clear yet if the benefits extend to non-motor functions. So the research question is the following. Does dance classes based on dance for Parkinson's disease improve cognition, psychological symptoms and quality of life in Parkinson's disease? And there was this article back in 2019 from Neuro Rehabilitation that explores that. So shall we dance together? All right. So methods. There are three phases. Excuse me. And they use participants from Queensland, which is in Australia. And it was the following. So we had a baseline assessment that is assessing for cognitive gait, balance and quality of life. That was one week prior to dance classes. And then we had the interventional period, which is 12 weeks or three months. That is one hour of dance for Parkinson's disease classes twice per week. And we had that treatment as usual. So without the dance. And then we had a post assessment, which is the one week after completion of dance intervention. And participant inclusion criteria was basically the clinical diagnosis of idiopathic Parkinson's disease, ages 40 to 85 years with mild and moderate stage disease, with no dementia and no other medical abnormalities. And you have to be able to walk independently for over three months without assistive device. And so these are the outcome measures. I won't go too nitty gritty into it, but related to cognitive function, psychological symptoms and quality of life. And if anybody's interested, these are the measures that they really use. And here's just an example of what a trail making test is. So there are numbers and the participant had to kind of connect the dots in the order of numbers. And there's per A and per B. And they have a score at the end where they use to calculate their cognitive function. So now I'm not going to really tell you the results quite yet, but I want you to think with me. So get out your phone again one last time. And now, you know, the drill. Third time is a charm. So you are going to go into it and let me just see. All right. So do you guys see the question? So dance classes had a clear benefit in all of the following perimeters, except for which of the following. All right. OK. OK, I don't want to give you the biased answer, but OK, roll in your answers. Oh, OK. OK, nobody could win for quality of life there. All right. Are you guys sure? Are you guys sticking to your answers? Any doubts? OK, great. Stick to your again. Awesome. So the answer is cognitive function. And for those who chose psychological symptoms, thank you so much for still participating. You guys are awesome. So for cognitive function. So let's talk about that a little bit. So it is actually a little bit a trick question because it did have some, I guess, benefits to cognitive functions, but not all parts. So if you go to the next question, what do you predict to be the only aspect of cog? Well, not the only aspect, but it is one of the only aspects of cognition to improve in the present study. What are your thoughts on that? All right, just a few more. Nice, okay. All right, so whoever chose episodic memory, can I put you in the spot a little bit? So can you turn your mic and camera on and can you tell me why you chose episodic memory? Don't be shy. All right, well, okay, I didn't wanna put you on too uncomfortable zone here. So let's go back to our main PowerPoint over here and we'll get to episodic in a second. But thank you everybody for your participation. So in terms of results, and thank you for thinking with me here. So group comparison of pre and post change scores showed a significant improvement with Dan's intervention for psychological symptoms, especially depression and anxiety, quality of life and selective cognitive skills. So here we see episodic memory has some significance, especially with auditory and verbal learning tests and some executive functions and processing speed. And going back to episodic memory. So episodic memory is sensitive to decline both during normal aging and brain diseases. And is actually one of the first cognitive function that is susceptible in your degenerative disease like Parkinson's. But in this study, the authors are speculating that there may be some positive effects on episodic memory as it require participants to learn some movement sequences stored these in memory and recall and perform special postures or positions and relationship and paths. And with episodic memories, just remember that it is actually a former long-term memory and it is actually really linked to your emotions. So if you're dancing and kind of feeling things, you can kind of easily take those memories out. So that's a little bit episodic memory for you. And then some other cognitive tests did not benefit from the intervention, possibly because the participants actually had a good general cognitive functions. Because one of the criteria was no dementia and they were relatively well-educated, reducing the scope for improvement. So of course, there's always gonna be some limitations to any study. And in this case, the limitation was some small sample sizes. There were 16 in each group. So that's pretty small. Some possible study bias due to no blinded assessments of outcome and no random sampling that resulted in unequal male to female ratio in two groups. And that requires some fully randomized trial in the future. And so I wanna just kind of sum that with just like the impact of dance and music because dance involves focus and conscious attention and a movement in synchrony with the accompanying music. And that leads to up to three minute formal day tasking. And dancers are encouraged to express their feelings and tap into emotions. And that could actually increase motivation and provide enjoyment, hence the improvement in quality of life. And music induces stress of mind, increases the release of dopamine from ventral striatum and ventral tegmental area of our brain. So in conclusion, we have dance classes that has a clear benefit in all these non-motor symptoms that we have talked about earlier on and especially emphasis on limited cognitive benefit. And others suggested that frequency of one hour class that's twice per week will be effective for future rehab. And some follow-up assessment is required to confirm durability of these effects. So I want us to kind of leave with this final quote here. Life isn't about waiting for the storm to pass. It is about learning how to dance in the rain. And this past year, we went through a lot, but maybe continue to dance when hardships come. So thank you very much. Thank you for listening. All right. And for the sake of time, I want Casey to talk about yoga because yoga is super awesome and she worked so hard to prepare for this. So if anybody has question, I will put my email in the chat and feel free to contact me. And with that, Casey, they're all yours. Thank you. Go ahead and take it away, Casey. Thanks, Haijin. Hi, guys. I hope everyone's doing well tonight. I appreciate you sticking with me as the last presenter. I know I'm smiling ear to ear right now after Haijin's amazing presentation. That was so fun. I'm sorry. I'm apparently technologically challenged and trying to share my screen. So give me one second. Sorry, it's happening. I promise. Okay, you can see what slide I'm on, but that's okay, right? You guys can see, it's all fine? We can indeed. Perfect. Okay, so I'm gonna get started. So my name is Casey, third year med student at CCOM, and I am presenting a review today. It's called The Effects of Yoga on Symptoms, Physical Functions, and Psychosocial Outcomes in Adults with OA. And it was published five years ago, so a little bit old in the American Journal of Physical Medicine and Rehabilitation. So I decided to choose this article because I love yoga. So these are all me doing yoga in weird outdoor places, trying to get good pictures for Instagram. So I think that yoga personally has really helped me. So as physiatrists, obviously, we wanna offer our patients the best evidence-based care. So I thought it would be interesting to do a deep dive into the literature on yoga and see if it would be beneficial to start including into patient care more often. So relevance of this article. When this article was written, 26.9 million Americans adults had been diagnosed with osteoarthritis. I looked up more updated statistics according to the CDC, up to 32.5 million this year, which makes sense because as the population, I feel like this is, I'm sorry. There we go, that's better. As the population continues to age, OA will continue to be progressive and just be diagnosed more and more. And I know personally, I saw a lot of OA on my rotation so far, especially family medicine. So just super relevant, causing our patients a lot of pain and there's not a ton of things we can do about it. So anything we can do helps in my opinion. So we're gonna look at yoga. So I just wanted to include a little bit the treatment algorithm, the standard of care. I got this from UpToDate, so not the be all end all, but this is what this is. This is specifically for knee OA, but same principles apply to any body part. So for mild OA, mainstays of treatment are diet, exercise, topical NSAIDs. I did highlight right here that yoga is one of the exercise methods that they talked about. So that's what we're gonna be deep diving into. And then for moderate OA, we add on some, maybe some oral NSAIDs, stiloxetine, maybe some cortisone injections like Francesco talked about earlier. Depending on the patient, we could add knee braces, canes, things like that. And then worst case scenario, refer to ortho for knee replacement. And again, yoga. So just defining yoga, they use the definition of a mind-body practice with its origins in ancient Indian philosophy. So there are tons and tons and tons of types of yoga. This paper specifically mentions two types. So Hatha yoga and Iyengar yoga. Not sure how familiar you guys are with yoga, but Hatha is basically an umbrella term that encompasses a ton of different types of yoga. So it does include Iyengar in it, but basically it's exactly what you would think of when you think of yoga. So poses, breathing, meditation, all that jazz. Iyengar specifically focuses on precision of poses. So the teachers are generally required to have a little bit more training and they'll use more props, chairs, blocks, bolster straps to get the participant in the best possible pose. So the goal of this article was to examine how the effects of the yoga are managing the symptoms. So they included anybody, they included studies where participants were over the age of 18 reporting OA symptoms being treated by yoga. Simple enough, right? Excluded any studies that focused on the mindfulness meditation aspect of yoga. They really wanted to make sure that physical practice was being included. They excluded if the article was unavailable in English and if it was a single case report. So this is just like a little summary of how they picked their articles, did their database search of over a thousand, narrowed it down based on the inclusion and exclusion criteria, and they got to 12. So 12 studies are included in this review. After they looked at their studies, they wanted to assess for risk of bias. So they use this Downs and Black Quality Index. I had never heard of it. It has well-established validity, meaning basically it's measuring what it says it's gonna measure. So they analyzed all of their articles and they did include a summary. So I have it right here. I'm not gonna go in depth, but basically if the score is over 23, it's a high quality article, low risk of bias. Under 12, low quality article, high risk of bias, and anything in the middle is that moderate article. They found that one of the articles they chose was high quality, one was low quality, and the rest were kind of in that middle range. So the overall characteristics of the participants in these studies, there's 589 total, ranging in age between 51 and 80. A few of the articles look specifically at Handoe or Niue, but most of them were non-specified. And then most of the articles took place in the US followed by India, and then one article each from Iran and the Czech Republic. So right here is a summary of all 12 of the articles. So maybe you guys are experts, but I'm definitely not. So I wanted to just include some terminology of study designs because I had to look them up. So quasi-experimental is a non-randomized study. So it's estimating causal relationships. So the researcher is in total control of who's in the treatment group and who's in the control group. So there are definitely concerns with internal validity and bias associated with studies like that, just inherently because the researcher is controlling who's going and what. Whereas randomized control trial, I think, is what we usually think of when we think of clinical experiments when their participants are randomly allocated into groups. And then pre-test, post-test studies mean that they're measuring the dependent variable once before and after treatment. Pilot studies are kind of preliminary studies, looking at the feasibility to scale it up. One of these was a pilot study, and then a single arm study means no control group. So I just wanted to highlight the types of yoga specifically used. They've varied a lot between the studies. Three of them measured Hatha yoga. Two, actually three measured chair, one of my boxes isn't working, sorry about that. And then three measured Iyengar specifically. Two were unspecified, and then one was integrated yoga, which is actually pretty interesting. It includes like devotional songs, lectures, specific counseling about yogi, concepts of disease and health. So we're getting a pretty big variable of the types of yoga being looked at. And then the control, so we're also super different. Some of the control groups got no care, some got education, some got standard of care, whatever that may be. I just wanted to point out two specifically. My top box, their control included EMG biofeedback, knee strengthening, and TENS, which I think is probably the most intensive control of all the studies. And then one of the controls was Reiki, which I just wasn't sure if people were familiar with. So I just wanted to make sure everyone knew what that was. So it's an alternative treatment method that basically relies on the therapies of energy healing. So the practitioner will place their hands either above or on the patient's body. And like they work to promote physical and mental healing by energy healing. I don't know how scientific that is, but that is what that is. So just in case anyone wasn't sure what that was. So the first measure we're gonna look at is pain. So that was measured by 11 out of 12 of the studies. I did include the specific measures of each study in that table on the right, but I'm not gonna go into the nitty gritty of that. The most common things used were the WOMAC and the visual analog scale, which is the faces that I think we all know and love from clinic. So main results of this are that eight out of 11 of the studies that looked at pain showed statistically significant improvement in OA pain. So, oh, before that, I just wanted to show you guys what a WOMAC looked like. It's the patient fills it out and it looks at their ADLs and they kind of determine how they're able to function. So that is what they use there. So this is a summary of the results. Again, I'm not gonna go specifically. If anyone has any questions, like feel free to speak up. If I'm saying something that sounds stupid, tell me, totally fine. You guys are all a hundred times smarter than me, I know. So what they looked at was pain intensity, stiffness, crepitus, pain with walking, pain with rest, tenderness. And overall there was a lot of improvement seemed and all saw in all of the studies. Only one study did not see any change in pain quality. So these results are indicating that there are positive effects of yoga on pain in patients with OA. The next outcome they were looking at was physical function looked at by all 12 of the studies. Again, using a lot of different measurement tools, they could use the WOMAC function subscale, six minute walk test. Some of the studies looked at sleep, BMI, stuff like that. So three out of the five studies that specifically use WOMAC cause we could compare all of those saw that the yoga significantly improved physical function, but it was a little bit more mixed results over here. So items measured included the functioning subscales like I just talked about, gait speed, balance, range of motion, sleep, one study saw no change whatsoever. And a few did see change, but it wasn't statistically significant. So, you know, for the purposes of this, no change really at all. So overall mixed results on whether or not the yoga helped with the physical functioning aspects of their arthritis. And then the last thing they looked at was psychosocial outcomes. So this was only looked at by seven of the 12 studies. And again, overall, we kind of have some mixed results. So they were looking at measures such as wellbeing scores, depressive symptoms, life satisfaction, things like that. Three of the studies did show statistically significant improvements in psychosocial outcomes, whereas two saw improvement that wasn't statistically significant and two saw no improvement whatsoever. So this is my favorite slide, at least. There were no adverse events. So whether or not it worked or not, I mean, we just talked about the results, but we'll get into discussion. At least nobody got hurt. And I do have my asterisks because only eight of the 12 studies specifically mentioned it, but they're assuming that if they didn't mention it, nothing bad happened. So it seems to be a safe treatment for our patients. So kind of onto the discussion, I've already said this before, but it seems like yoga had the most positive effect on pain associated with osteoarthritis. A few hypothesis, a hypothesis, that's not a word, sorry guys, hypotheses on why that might be. Yoga promotes the relaxation response, which will increase parasympathetic nervous system activity, decrease sympathetic nervous system activity, and kind of decrease the pain in that patient. The other thing is that pain is subjective. And if someone's going through yoga and going through mindfulness training and mental awareness, they might be perceiving the pain differently. And I don't know if you guys noticed, but back in that moderate OA treatment algorithm, I don't think I pointed it out, but cognitive behavioral therapy is a treatment sometimes people will use for severe OA. So it's kind of the same idea as we can affect the pain. I mean, not a hundred percent, but definitely a factor that might be playing a role. Five of the studies show that yoga could improve symptoms other than pain. So that includes crepitus, swelling, things like that. So not conclusive results by any mean, but indicating that yoga might be helping with things like that. There was inconsistent findings, like I said, on the effects of yoga on gait, speed, strength, flexibility, stuff like that. There have been previous studies showing that yoga did help with factors like this. However, the study kind of mentions how the previous reviews all focused on healthy community dwelling adults, whereas this study really had people with underlying health conditions, advanced age, and then maybe the like beginning level of physical pain and impairment could contribute to that as well. Something that we haven't talked about yet is dose effect. So the review did see a strong positive relationship between the number of yoga sessions per week and the efficacy of yoga and helping with the physical functioning and emotional wellbeing. So the studies looked at, some of them had daily yoga, some of them had weekly yoga. So obviously that's a huge difference when you're looking at how much yoga someone's getting. It's like taking one Advil a week versus like 30, like it's just so different and no one was really looking at that. So I'll talk about that later, but something that definitely needs to be considered more. But a noteworthy thing was that the pain did seem to decrease regardless of the dose. So last part of the discussion here, again, psychological health showed mixed results. The study does acknowledge that ceiling effects may have contributed to these findings. So what that means is if adults in the study are already coming in with a positive outlook on life, there's not much more room to go with that positive outlook that'll look statistically significant. So it could be a factor, but kind of unclear on the why there's mixed results as of this point of the review. So limitations of this study, like I kind of talked about before is only one of the trials was shown to be high quality. So definitely worried about some risk of bias with this review. Only studies written in English were included, which may or may not be a huge factor, but in this study, it might be just because yoga is so prevalent in Eastern culture. If you're having like science done over there that isn't being translated into English, we might be missing that part of the research. Just, you know, small limitations that possibly missing stuff in the database search or misinterpreting the like risk of bias. And then the last thing was that they couldn't do a formal meta-analysis just because of the varying types of yoga frequency, kind of like we talked about before in the limit amount of random controlled trials. So the overall conclusion is that there's insufficient evidence. So not the funnest conclusion for a paper, but still helpful. Yoga may be used to relieve O8 pain, but we can't say definitively if it does or not, but it does seem like it's safe and a therapeutic option for our patients. Maybe that it might work for them and we could definitely encourage, but I'm sure there's been more research since this is 2016, but definitely have a lot of future work that I wanted to point out. So like I said, more long-term studies needed to look at the effects of yoga on psychological outcomes and whether or not they'll persist if the yoga treatment is stopped. More research is needed to look at the effects of yoga on sleep, daily activities and spare time activities because only one study each was looking at factors like that. Studies are needed with larger sample size. Like I said, the total amount of patients for all 12 studies was 589, which just really isn't enough to make a good conclusion. Also studies should take into consideration yoga adherence. So something not talked about by any of the papers, which I thought was interesting is, is someone supervising the patients while they're doing yoga? Who is leading it? Like various teachers teach so differently. Yoga varies so greatly even within the teachers. And if the patient is doing the class at very high intensity, or if they're laying on the floor, which are both great by the way, as a yogi, like I would love to go to the class and lay on the floor, but you're definitely getting different physical outcomes from that. So definitely something that needs to be looked at is exactly what the patients are doing and the intensity of that. So that's kind of leading into my last bullet point, which is that looking at the types of yoga that might be best to help treat patient's pain or function, duration of practice, intensity and frequency. So that is it for me actually. So I just wanted to thank you all so much for listening. If you have any questions or comments, I'd love to hear them. And I have my references too. So thank you. Awesome. Thanks to all three of our presenters and Casey for that great presentation as well. What questions do y'all have? All right. Our three presenters left everyone completely speechless with the quality today. So awesome job from all three, really good stuff. I prematurely put the word plugged in the chat here just cause I wanted to start plugging away, right? So we have this every month on a particular Tuesday. The next one is May 18th. A couple other things, just follow the AAP Medical Student Council on Twitter. We have a lot of exciting content from a lot of our student council are really excited about coming up. One we're particularly excited about for the MS4s and MS3s out there, it's not too early to start looking at programs out there. One of our features we got going on now is we got the program director constantly being retweeted on our Twitter page, talking about what makes their program really special. So really awesome programming out there. And with that being said, right, thanks for all y'all for staying out a little longer for us and really excited for presentation in the future and wanna just give a kick, another air clap to our presenters again for a really good stuff tonight. All right. Thank you. Thank you. Take care. Thanks everyone.

presentations

informative

engaging

yoga

osteoarthritis pain

dance

cognitive function

Parkinson's disease

guidelines

managing pain