one. I think we can probably get started. You know, I think some other people will filter in as time goes on. It's always a little challenging for these weekday sessions. Ravi, Dr. Kassi, would you like to begin or I'm happy to get started with the introductions of the program? Yeah, let's do the introductions today. That's totally fine. Yeah, great. So, welcome everyone. My name is Carly Sautter. I am a PM&R physician associate professor up at Medical College of Wisconsin. With the AAP, I work with the Medical Student Educators Council and within my own school, I do medical education in a couple different settings. So, anyway, today we want to welcome you to our program, which is thinking about all med student development as we start to think about your careers going forward. We have a very fun program planned for today and tomorrow. We hope you can all join us tomorrow as well. As you know, we're going to have a program that includes some didactic topics, some personal stories about career development and people's different pathways through PM&R. We'll have some student debate on certain topics and we will also have a quiz bowl. So, again, oh, and also with some very exciting prizes. So, we love the more that all of you can participate, the better. What we are going to start with today is one of our journey stories. So, but before we get started with that, I'm going to let Dr. Kassi introduce himself and then we'll get started. Hi, I'm Dr. Kassi from Rush. I'm the program director here and I don't want to take up any more time because we want to give Dr. Pacheco as much time as possible. One more really quick comment, though. We really prefer if people have cameras on during the session, if possible, and if you would like to add in your year of medical school and or your medical school that you're coming from in your Zoom box, that would be great. If not, that's okay, but it's just another way for us to kind of connect to each other and meet each other and start making connections around our specialty. So, anyway, go ahead, Ravi. You can introduce our first speaker. All right. So, our first speaker is Dr. Marilyn Pacheco. She works at the Edward Hines VA here in Chicago, Illinois. It's nice and warm right now, but if it was wintertime, we would say in the bitter cold. Dr. Pacheco was one of my teaching physicians and she is amazing, which is why we wanted her to give a talk today. She's the chief of rehabilitation services at the Hines VA. She's board certified in everything, DMR, spinal cord, brain medicine, and she has an incredible story. So, we wanted to have her talk about her story of how she became who she is. And I just want to kind of leave the floor up to Dr. Pacheco to tell her her story, and then we'll have plenty of time at the end because I know you're going to be inspired and have a million questions of how you can do what she's doing. So, Dr. Pacheco, the floor is yours. Hi, thank you. That's such a wonderful welcome, Dr. Cassie. As Dr. Cassie said, he was one of my last residents before Oak Forest closed, so I'll get to Oak Forest and all of that. But my journey is very, I was like thinking about it last night, what do I call my journey? It's slightly twisted, I think. There's a lot of twists and turns in my journey to where I am now. Currently, I am the chief of rehabilitation service at Hines VA Hospital. We are located at Hines, Illinois, which is just by Loyola University. And my journey started, I am a foreign medical grad. I came from the Philippines. I did my medical school there, which is slightly different than medical school here. During our fourth year, we are called interns already. We're called junior interns. So, we're on call every other night, which doesn't happen anymore, I'm sure, because of ACGME. And during one of my rotations, I followed my patients into rehab. And then from, because I like every rotation, I'm sort of like, oh, I like medicine. Oh, I like OB. Oh, I like OFTA. I like every little things. And then this one, during neurology rotation, I followed my patients to therapy. And there, behold, was the hidden office for a physiatrist. And then we started talking. And then that got me interested, like, oh, there's more than just diagnosing a patient with a stroke. I can get them to rehab, and then they do get better. I work with interdisciplinary, and then I'm like, okay, let me learn more about this. So, after that, graduated. But in the Philippines, before you could take the boards, you have to do another internship called the senior internship, which is our, we're called PGY-5 at that, well, not PG, we're called PGY-1, but then it's an internship that's not paid for. So, went to the Philippine General Hospital, and they have a big PM&R service. We have about a 20-bed unit there, which is considered big for a government hospital, mainly spinal cord and brain injury patients. But what got me to, like, solidify that I wanted to do PM&R was my pediatric patient, who is a thalidomide baby. Have you heard of thalidomide? So, it's used as birth control in the past, and this three-year-old had no arms and no legs. And he came to us as a three-year-old from the province, which is a three hour drive, and we have to give him legs and arms. And that was a challenge, because he's used to bumping his bum around without a leg or without any arms, using his, like, he has this little claw, like, almost like a crab. And he could pick things up, so he didn't want to do anything. And he was miserable because he's missing mom, because mom left him with us, inpatient. So, it was quite challenging, but that solidified, like, oh, I want to do PM&R, but I thought PEDS. So, that's why it's called Twisted, because I thought PEDS PM&R. So, when I took the USMLE Step 1, Step 2, I took it all at the same time. Not like you, you'll be taking it second year, and then during around third year or fourth year for Step 2. We took it all the same time. At the same time, I took the Philippine boards, and then look into how to get here. In the meantime, I was working as a general practitioner in the Philippines. So, I was doing minor surgeries here and there in a local community. I was doing moonlighting, so you could moonlight in an ER, delivering babies, treating asthma kids, and all of that. So, that's why it's Twisted. So, to get to the United States, you have to apply. Like anybody else, you have to apply to all this residency, but it's not like now, it's all electronic. Those times were all paper. I had to send out a lot of mail, spend a lot of money on mail, and got the interviews back before I could come here to get the visa to come here to interview. First round, I thought because I thought I had to do PEDS before PM&R. So, first round did not work well there, because my planning was incorrect. So, Twisted. So, I went for the second round, and I already practiced for about a year and a half then in the Philippines, and then came here. I was lucky that there was a categorical spot at Rush, and Dr. Nicholas, God bless his soul, he passed away a few years ago, was my program director and the chair. No, the program director was some mayor, and he was the chair of the department who got me in the categorical spot. So, I'm always very grateful to Dr. Nicholas to give me a chance as a resident starting internship again in internal medicine. Categorical spot at Rush is all internal medicine. It's not transitional. And then did PM&R, and I was like, you know, at that point, life happens, right? I was already married during residency. I had a kid. So, it's got twisted. Of course, like, can you buy, like, do you want to balance life and PM&R? Yes, you can. But I have a, I had a very supporting, supporting husband. He supported me all through residency and through fellowship and all the things that I've done. So, until he passed away. Let's see. Had PM&R, and then I was the chief resident. And I was thinking, like, should I do, my first love is brain injury. And then I was thinking EMG. And then I was thinking spinal cord. So, I like those three areas. I got, I got, I got matched for brain injury, but that fellowship grant got pulled out. So, I had to scramble at the end of my residency. And I scrambled into spinal cord injury in Texas, which I was lucky because at that time, they could just offer it right away. Once you interview, they offer you the spot. And I was offered the spot right away then. So, I was lucky. We did have to move to Dallas. And I was always very lucky in the people who have mentored me through the years. So, always been grateful about my mentors. I have, during residency, Dr. Rieger was there. Dr. Neiman was there. And then of course, we were, we rotate throughout Oak Forest Hospital, which we had good attendings, which actually was where I developed my SCI love and TBI love because there's two units there for all SCI, all TBI in between the intermixed stroke patients and burn patients and all the others. But it was because of that rotation, I rotated at Oak Forest Hospital for, I keep asking to go back to that rotation. If anybody could switch, I go back there. So, I rotated back there at least almost a year Oak Forest rotation. But the last three months was more an elective. I was doing SCI, doing wound care, and then I was doing EMG. So, it was, I was able to, again, twist this thing into like what I need and what I think I want to do. So, I'm not the typical that I went in and this is what I want to do. Like I said, every rotation too, I said like during medical school, every rotation was fun. Every rotation was fun for me in residency, but I do love the SCI and the TBI population. So, that's why I did scramble for SCI. At that point, it was too late for me to even think about EMG rotation. So, if anybody are, any of you are interested in an EMG rotation, I would start out a rotation early during residency, so that you could start thinking about it during your third year. Because by the time I rotated, all my EMG rotations were fourth year. So, I had seven months of EMG rotation, but all fourth year. Because four months was two required rotations. And then the last three months, like I told you guys, I kind of intermix it into what I want to do. So, if you're thinking, if you're interested in EMG, ask for that rotation early in your program, if you're interested in that. So, I did that. And then in spinal cord, I went to Dallas. And then the fun part about that is that UT Dallas was also model system for TBI. So, guess what I did? Was after my wound care clinic or any clinic that I have, I'll run to go see the TBI doc. And then if he has, she has any patients, I'll watch and then I'll help out with some of the intake and all of that. So, I learned from that. And Dallas is also burn unit and Fela Helm created that, you know, the burn unit, right? What's the formula? Parkland formula. So, that came from where I'm rotating at. So, I visited the burn unit too, where SEI and TBI are at. So, it's just a very interesting rotation and a lot of VA. So, it's partly sponsored VA fellowship, half VA and half UT. So, I was at the VA six months and then UT divided like plus, minus, I was at Children's Hospital in Baylor and then also the Spina Bifida Hospital there in Dallas. So, it was a very, very cohesive and I was lucky that fellowship was run by excellent people. I had Dr. Michael Preby was the program director then and took over by Dr. Lance Getz, which is there. If you see them, they're in the chapters of the spinal cord books and they're in the clinical consortium, their names are out there. And then I had fun in SEI. That's where it became fun. So, another thing that I do right now is spasticity. So, my spasticity journey is very complicated, not as complicated, but rush. So, spasticity and then the pump, the intertical baclofen pump was developed by, I forgot his name, I'm blanking out, sorry. But it was developed by this doctor neurosurgeon that work at Rush and then also work at U of C. And then so, who is following all his refills and reprogramming and all of that during that time was the Rush PM&R department. And we had not the pump that is really nice with an iPad now for programming and things. We had the big computer, like the old Apple computer attached to where you have to do things. So, that got me interested in spasticity. We were doing a lot of phenol then before the popularity of the botulinum toxins. And I was really good at the pumps and then trying to get into the pump for reprogramming. So, Dr. Mayer at that time, let me do a lot of, most of all his refills, I'm doing it. So, that carried me on to spinal cord, which in fellowship, Dallas has a very, very big intertical baclofen spasticity program included in the SCI fellowship. So, we were doing weird stuff. We were doing clonidine. We were doing clonidine in the pump with the baclofen. So, other things, right? But here's another twist to my story. I was on a J-1 visa. If there's any, J-1 visa means I have to go home to serve two years there and come back before I could apply for an H-1 visa, which is a working visa. So, because of my son, I needed to stay. And then my husband, he's a citizen. That's another story. My visa story is another long, long story. But anyway, short story to that is that I was able to find a J-1 waiver, which I was very lucky because it was at the University of Arkansas. So, University of Arkansas for Medical Sciences. And again, another lucky part to that was that Dr. Kevin Means was my chairman, and then he was very supportive. I thought I was going to go through the academic track. So, this is the other twist to that is the academic track. I was hired as the spinal cord doc, and also the spine doc. Believe it or not, spinal cord became the spine doc also, treating back pains and all of that. But at that time, Botox is starting to get very popular. I was doing a lot of the specificity outpatient. Aside from that, consults, which is, the consults there is huge because it's the whole university hospital. So, I'll be running a clinic in the morning, do the consults in the afternoon. And then in between that, I'll be covering the inpatient units for my partner, who's an SCI doctor. He is more SCI than TBI, but I'm more a combination. I like that dual diagnosis, and then I like each diagnosis. So, I was able to contribute to that practice in that way. But family calls and then need to change again. So, the twist there is we came back to Chicago, not had to come back, but it was good that we did come back for family reasons. And then I work at Oak Forest Hospital. Thinking about joining other practices during that time, but Oak Forest for me was the best match because it's the TBI unit, which I really wanted to run during residency because Dr. Niroconda was like, hey, Marilyn, when I retire, take over my unit, that thing. And then I was like, okay. But during fellowship, they hired somebody else when she retired. And I'm like, oh, I'm not going to get that job anymore. But never know, life has its own plans, right? I was looking, the job opened. So, there. And then I was all set. I'm going to retire as a Cook County employee. Okay, all set that way. But life happens. Cook County had issues with funding, and they closed down the entire hospital in 2011. So, that's where my journey to the next job, which is Schwab. Schwab was all specificity and all TBI for me. It was a very good experience. At Oak Forest, very good experience because I love Tess. Tess is a friend. Dr. McCarty is a friend. And I love the therapist there and all of that. I do still miss Oak Forest up to now, and it's been 11 years. Schwab was a breeding ground in terms of, like for me, learning ground from Michelle Gittler, who doesn't know Dr. Gittler, right? She's very, very popular in APNR and in the physiatry world. And she opened like my mind into like, oh, be active in this, be active in here and doing things. And then I was able to do a lot of things. But again, where I live to Schwab, my kids are still young, was sometimes when it snows in Chicago, it takes me two hours to get home. So, my husband was like, hey, think about something else. So, I had to think about another work. And then lo and behold, another opening. Because VA, usually we have mostly, here, mostly outpatients, okay? We have a very small inpatient unit, 10-bed unit. And then when, oh, I forgot, when the twist there was that I was applying for the VA job, but I wasn't a citizen then before Schwab. So, they needed a citizen. So, I wasn't a citizen. That kind of forced me to apply for my paperwork really fast. But they took somebody else. And that was for a plain SCI job. Because we have a very big SCI center here. It's a 60-bed SCI center. But that, I think, did not work out for a reason. Because I got, the next thing you know, I got the job for the inpatient rehab here as the medical director of the entire unit, which is a small unit, which is a good unit to handle if there are other things that your chief wants you to do. And that's what I learned. Like, here in the VA, you can be assigned other duties. And if you want to grow in terms of your career, there's ways to grow. Dr. Monica Steiner was one of the reasons why I'm in this position. Because she's like, hey, Marilyn, why don't you attend the Heinz Leadership Development Program? Okay, I attended that. Hey, Marilyn, after that, why don't you attend the VISN Leadership Development Program? So I attended that. So she was, you know, behind the scenes, doing succession plans, which is really, really good. Because when she suddenly retired, which was not a good year for me, when she, that year, early 2020, I lost my husband. So at that point, I was, I was happy managing the unit, I was the section chief of the inpatient section, I was handling the consult. I was handling ECC. I was handling a lot of things. But that year was horrible. I thought I was going to quit. I was not going to be a doctor anymore. So it was a very challenging year. Up to now, it's still hard to talk about that year. But Dr. Steiner retired end of July that year. I lost my husband around end of last week of February that year, before COVID shut down and all of that. And then COVID hit, right? So everybody's experiencing the COVID things. But that made me like, oh, do I want to continue with my medical directorship duties? Or do I want to like, because I don't want to see the department and the entire service. How is it going to look like? Because I decided that I have to continue because I have kids to send to college too. So I have bills to pay. That's one thing. As we grow older, kids grow older and college is expensive. So think about that. And so I was like, okay, let's try to apply for this position. It would give me more balanced time. I kind of sort of I'm ready for it because she did like, I was calling for her once in a while. There are like about three of us that are assistant chiefs calling for her. Any of the others, I would be happy if they were chosen as chief, but the others like, I was told like, yo, why don't you run? Try and then for me, it was like, why don't you try for it? It keeps you busy. It gets your mind off things. So it did keep me busy. It is challenging. I love the service. So I fortunately got the job, or unfortunately, and it is keeping me busy. It is challenging every day. I'm still learning new things. I kept, I still go on calls for the inpatient unit. I still do like my inpatient section work because we still have to name another section chief to take over that. I kept my spasticity clinic. So I did, when I came to Heinz, there was no spasticity clinic at all. So I slowly build that up. And then now we have a big, not quite a big, but there's about three, four of us that doing spasticity here. I'm the only one doing intertical baclofen pump in the service, but most of the SCI docs, which is separate from the rehab service, are doing intertical baclofen pump. So my journey is twisted. In between there, I have research. In the VA, there is research. That's one of the things that I like. So like I said, it's not just the medical directorship, which is small, right? So I was busy with research. I got recruited to be the clinical scientist for the transcranial magnetic stimulation for the disorders of consciousness for brain injury patients. There are papers out there. And we had another one that just got published, but that kept me busy. Other things that I do here, which I do the IRB. So I'm not just stuck with reviewing PMNR stuff in terms of review board, but I still review in hematology, oncology stuff for IRB for doing research. I get to review lung cancer things, urology things. The IRB kept me interested in things, in medicine itself, because you don't want to lose touch with the other areas, right? So that's my story. And then if you have questions, let me know. It's just very twisted. And then I've been, I like teaching. So I've been teaching, so I've always been in a teaching program. So that never left me. And the reason, and then the one thing that I'm very grateful for University of Arkansas was that as a fresh, like a first year assistant professor, you're required to attend a teaching program for one year. It's a class for one year wherein you get a certificate on how to teach. And that actually helped me improve the way I teach. So a little twist and a little turn. Questions? Robbie, do you have any questions? No questions. You know me too well. I think you're mute. Yep. So I had one question because I think all this, you've done a lot of things in your career, worked at a lot of amazing places. Work-life balance, I know you touched up on it, on your work-life balance, but what have you learned from your career? I know you touched up on it, on your work-life balance, but what have you learned on that journey? Because as students say, hey, I want to achieve a lot of things. And I think I'm too much of an old school model of, you've got to sacrifice everything. You're not going to have fun and your life is going to be miserable. And then 15 years later, you're going to be having achieved a title. What is the advice that we should give the students on creating that work-life balance, but still getting all those work certifications, all those positions that you got, what did you do? Well, I had, like I said, I mentioned my husband. He sacrificed his career for me to be able to develop my career. He's a manager, so he stayed at home with the kids. We could have hired nanny, but then at that time, the nanny scare on abuse of kids, that was when I just had my first child. And then we were like, oh, we're not going to do this. And at that time, it was residency money. And it wasn't that great. One of our salaries, just going to the nanny. So we made that sacrifice. One of us made that sacrifice. He made that sacrifice. Throughout when to take the boards, I'll be waking up to study for the boards. I'll be waking up at four in the morning because I already had the baby. If the baby wasn't there, then I would have, the baby actually made me manage my time better. Believe it or not, the more things I do, the better I am at my time management. It's weird, right? Because when I have a lot of time, I tend to waste it. And then when I don't have a lot of time, I tend to manage it better. So it's all time management. So it's all about, what is that? Like, well, do you really need this? Like board certification? Yes. Yeah, I really need this. What do I really need to get to the next step to the next step? It's always, and then I'm a big proponent to have like one year plan, three year plan, five year plan, 10 year plan. And then when am I retiring? I have a plan for my retirement already, even though that's still a few years away. But I planned that out, like I planned it out to 30 years, what it's going to look like. So work life balance, it was, it is challenging. But you know, when there's conferences, I drag my kids with me, my husband's with me. And then in between conferences, we'll go have fun. When there's projects to do, I will stay, once the kids are sleeping, I'll make time, like usually it's the kids first, dinner first, kids first, then I'll make time at night, and then I'll go to sleep. I'm one of those that I love my sleep, but I can sacrifice it. If I get six hours, I'm fine. And then I'll just like catch up on the weekend type thing. So time management is there, should be there. I have fun when I like it's not, there's no, I don't find it like a work life balance thing issue. My kids do understand though, oh, mommy's doing her doctor thing. You know, mommy's doing her teaching thing that's they know, they know when like, oh, is that your student? Or is that your resident? Or is that your, your co-doctor? Yeah, they'll, they know, they know what I'm doing. So I never excluded them. Sometimes when I'm studying, so I'm studying again for my third board, like, you know, those recertification, they're like, oh, okay, we won't bother you this time. But can we do this thing? So they know when to make schedules with me also. But they're all grown, like, my son is a senior in college now. And my daughter is going to be a freshman in college. So she's starting end of September. So it's, it works out. I think if you have a good partner, or husband or spouse, or, and then you have good family that understands, because my family understands. And then there are those long vacations to the Philippines to visit my parents, of course. That part that is a big break. I do not bring work at all when I have those long vacations. When I go on vacation, vacation, zero work, I don't even have my computer with me. Sometimes I'm off the grid, you can't get a hold of me. So that's one thing you have to do. Like you have to know when to cut off. Vacation is vacation, family time is family time. Of course, there's emergencies. Nowadays, like if I'm here, and I'm just staycation, then they can bother me. But if it's like a big trip, no, no one, because that's one of the things like you have to know, like you need, what do you love to do? What do you love to do? You love to do big things, right? So you're going to spend big expenses for this, mostly with family. So that one, those two, I, I, I always like work for what I need, and what I want, what I like, and what I, I want. Those are very fleeting. And then if it doesn't hit, like, oh, am I going to be happy with this in next week, then I don't do it. If, if I'm happy with my decision for, for the next year, the rest of my years, then I'll do it. So those are the things that I do to balance my work life. And I'm, I came from a family, my husband's family is a family of doctors. So we speak the same lingo, although they don't understand. We have, my brother-in-law is internal medicine, and he's like, yeah, he goes to, to rehab, they get better, and they come out, they're better. That's what he thinks of PM&R. Dr. Pacheco, there's a couple of questions. We'll just take these two questions. The, the first question, I think I can answer it, or no, first of three, excuse me. I think it was Dr. Penn who pioneered the intrathecal Baxone pump, if memory serves me right. Richard Penn, yes, Richard Penn. Yeah. Helen has a question. Did you want to ask your question? Yeah. Hi, my name is Helen. First of all, I wanted to say sorry for your loss, and it really sounds like you've been through a lot on your journey. You've been through a lot of things, and somehow you always manage to, you know, pull through and keep going. Is there anything specific you have done for yourself only, not for the kids or anyone, just for yourself to, you know, stay strong and have the energy to keep going? I do exercise. I'm not, I'm not the exercise fad. I don't run marathons. I don't do that. I'm like into yoga, relaxation, meditation, things like that. I do Pilates, like things that are slow. I, I walk, like my husband and I will go for walks. We walk, you know, we go out. Those are the things that I do. Hobby wise, I, what are my hobbies? I like to read, not just, not just the medical books. I like to read all kinds of books. That's why I think my son is a creative writing major, because I have all those books at home. So, you know, I made him, like he was like, I made him read Harry Potter at second grade. It's my fault. All right. It's like, but that's what I do. I like to read. I like to spend time with family. I do yoga, Pilates, and I do walk. I need to go back to a lot of it because a lot of it, I did stop when he passed away because a lot of the activities that I do was as a couple with him. Now I'm, I'm doing yoga again. I'm doing Pilates still, but the walks, it needs, it takes time. I think I'm just going to walk the dog alone now. I do have a dog. We do have a dog. That's funny. And then one more question. Clarissa had a question. Did teaching come easy to you or was it something that you had to develop as you, as you progressed through your career? Did what come easy? Teaching, teaching. Teaching. I had to develop that because the teaching style, it's a development because I'm like, I'm old school. Here's the PowerPoint. And then right, right, right, right, right. The teaching certificate opened me to a different way of teaching, which I think Ravi was one of my experiments, right? It's like the individual, the IRAT and the GRAT, the group, group review questions, and then the individual questions. And then I send out materials ahead of time when I'm teaching to be read by whoever's going to like usually residents. And I expect them to have read those things because the first thing I do is I give them a test and then we'll go through each question, individual tests, and then I'll group them into like groups and then do group tests. And then I'll have them answers. And then I like doing those fun game testing, like the, what is it called? The family feud test. And then the, the jeopardy test. I like those type of lectures. And then when I'm rounding, I tend not to lecture in front of the patient. Because I, I don't think, if there's something that I have to show physical exam wise, then I'll show it there and then. But if it's something more lingo wise, the patient won't understand. I don't think he, you know, I would sometimes excuse myself from the patient that, oh, I'm going to be doing teaching. I always do that. If I'm talking in front of the patient, but I usually do my teaching separate from, from rounds. And then I do have like, you know, the work teaching, just like the fast cut list and then doing things. And then I have a set teaching time with residents. I always have a separate time. Because in the inpatient unit, it's very easy to carve out time if you manage your time correctly. Great. Thank you, Dr. Pacheco. Thank you. We, I'm sorry for, you know, there's one more question, but we, we should move forward. So we make sure that all of our speakers have time. So thank you so much, Dr. Pacheco. We really appreciate you taking your time and kind of telling us your story. Maybe you could give me that question. I can email and then answer it. Oh, of course. Yeah. And then it's, it's from Niranjana Kasi. If you can just email, send me your email, and then I can, I can have Dr. Pacheco email me or email you out your question. Okay. Okay. All right. So one of the things that Dr. Pacheco talked about is interests, interests outside of medicine. She talked about reading, taking walks, walks with a dog. So for all of you put in the chat, what are fun things that you are doing? Give me one hobby that you are very passionate about. And there's gonna be a reason why we're gonna bring it up. Walk my dog. Pinball. Jiu-Jitsu. Books. Off at Frisbee. Drawing. Soccer. CrossFit. Pottery. Fantasy football. Nice. Swimming. Biking. It's a great start. Why is that important during interview season? Give me two reasons. Extracurricular activities is what PDs love to talk about. Apparently. Right. And then Pooja got the other one. Pooja, do you want to tell us? Yeah. So basically like you want to know what we do in our free time to manage all the stressful things that happen out there in the hospital. So like coping mechanisms, coping skills, things like that. Yeah. All of them are good. I think the fantasy football one might be a challenge because that's only three months, four months out of the year. But we'll take it for now. But you know, the thing about it is, if you find yourself actually putting in what you think is a bunch of BS, because you're like, I really don't do much of anything other than study, you know, really think to yourself, what are the things that you're really passionate about? What makes you happy? And so that way, when you write it on your CV, it's going to be truthful because that truth will come out when we ask you questions. And I'm not taking the fantasy football one because I used to love fantasy football in my younger days. That would be the whole 20 minute interview talking about, you know, who should we pick up this week and the waiver wire and everything else. But it's a very easy way to connect with your patients for your interviews. And then of course, most importantly, for your own health and wellness, because you can always go back to that well to make you happy. So, Carly, what's your pleasure, I guess? For me, I mean, my kids, I spend a lot of time with my kids and my dog. And actually some of these other things too, you know, some of the things that other people said, I like to cook, try to travel, you know, sounds a little generic, but it's really true. And it does, you know, the need for an outlet, like in just developing yourself as a person never ends, right? It's not just medical school. You'll need that as part of your life forever. All right. So we are going to get to our next topic here and then we'll have a little bit of a break before we go into specificity. So we're going to do a little bit of PBI. Can everyone in the crowd see the PowerPoint, I hope? We've got two brave medical students, Jonathan from Rush and Dante, I think from Midwestern here in Chicago. They're going to help me with the debate. Full disclosure, you know, I gave them my professional wrestling analogy. You know, it can be a little bit scripted, which is totally fine, but we're going to have a little bit of a back and forth and a discussion about near stimulant medications and which ones would be quote unquote best, okay? A couple of things. I've got to tell you on why you should pay attention, right? There's got to be a reason to pay attention. Give me one, give me two reasons to pay attention here. Whoever got the Lego set, I love you. That's amazing. I love Legos. No one thinks they should pay attention? Come on. There's a quiz with money at the end. Should that be a good reason? Yes. Okay. So as we're going through this, I'm going to be giving you hints on things that may be coming up on the quiz. So just pay attention because me and Carly are giving away money on Amazon because Jeff Bezos says he needs more of our money. So we figured that might be the easiest way for everyone to kind of plug in. But if there's a specific store that you want a gift card to, like let us know if you're the winner. If there is a tie, we will go with a good old fashioned rock, paper, scissors, okay? All right. So to start off our conversation about the use of near stimulants, we wanted to paint a picture of the patient or patients that we're going to see, okay? And so let's think about this here, okay? So we can use Google resources. There's no bad reason to use Google during this lecture here, okay? So let's consider a 67-year-old male. He's admitted to the trauma unit and he had blunt head trauma approximately three days ago. And your job on the rehab unit and the call that you'll get is we want to send the patient to rehab. And you're going to say, well, gosh, this patient has not woken up. They have barely participated in therapy. We're not jerks. We just think this person's got to do a little bit more before they can get up and participate in therapy, okay? And so when we start that conversation, start that evaluation, you're going to want to determine what their disorders of consciousness is, okay? And there's going to be some lingo that's going to go back and forth that's going to be important for your audition elective. So we'll start talking about that here, okay? Now, have you guys heard of your Glasgow Coma Scale? Yes? Some of you have, right? Some of you have heard about your Rancho score, okay? So if your first name starts, or last name for that matter, goes from A to, what's the middle of the alphabet? What's 13 up? Anyone know? M, okay, fantastic. I was going to embarrass myself with the LMNOP part. If your last name starts from A to M, look up your Rancho score. If you're from N to Z, look up your Glasgow Coma Score, okay? Google it and look at the descriptions here and figure out how you would quantify this patient's either Ranchos or Glasgow Coma Scale, okay? We'll give you one minute, and we'll talk as a group. I'm over here, so this one. All right, so, and I forgot which, who I signed to whom. Someone from the letter A to M, who wants to volunteer to let me know what you found? So, please. Sure, I'll do it. So, I believe A to M was our Rancho score. So, I gave him a Rancho level two, his generalized response, but really just some reaction to painful stimuli. He's not really recognizing faces, anything like that. Some spotting, he's eye-opening. So, I'm gonna bring this over here because it's easier for everyone to see. Everyone can see. Can the screen, is it too small or is it big enough for everybody to see? It's good? Okay. So, was that Jonathan? Was that you? Great. So, this is Rancho's Los Amigos scale. Can't say anything today. And so, this is a scale that's commonly used on the rehab unit to kind of quantify this patient's level of alertness, agitation, somewhat of function, just a very gross scale. And it's a good thing for the students to know when you're on your brain injury unit because you might get a call about, hey, we're gonna get signed up from a patient coming over to the unit. And one of the questions that as you're giving your report, you might want to say, this patient is Rancho's X. And the attending and the resident will automatically know what level they're at. It's also gonna make you look good as though that you've read that big TBI book. So, it's a good starting point. So, it's a great way to kind of quantify where they are, to give sign out, to kind of paint a big kind of global picture. So, Jonathan, you felt like this patient was Rancho's, say that again. I said two. It could be closer to three. Yeah, it's a great example here. So, let's take a look here. Level two is just generalized reflex pain response, which I think this patient has here. With level three, you kind of need a localized response. You're blinking a strong light. You can kind of see that. And the key here is that when you're having a patient on the floor, they're not gonna always fulfill all these specific categories. There's gonna be some shades of gray. So, it might be somewhat confusing or somewhat difficult. Where they kind of get used more often, this Rancho's scale, is when you look at level four, five, and six. So, it's when you're talking about someone who's agitated or if they're appropriate or their level of confusion. So, that's kind of how the Rancho's scale gets used. It's just a very important tool for you to kind of know when you're on the rehab unit itself, okay? What about the, anyone else talk about the Glasgow Coma Scale? Who wants to go for it? Edward, do you want to let everyone know? I think you put into the chat. Sure thing. And hello everyone. Hi, Dr. Kossi. I would guess a 10 based on withdrawing, but not localizing, giving it a four, sounds with no words, giving it a two and spontaneous eye opening four all put together, giving the score of 10, being a moderate glasbicoma scale. It'd be a moderate brain injury according to the GCS. So, and Edward, when do you want to use a glasbicoma scale? I would think in any case of brain injury, when there is a disorder of consciousness that is suspected. Okay. Let's talk about timing. As we said, the Rancho scale, I mean, you can use it at any time, but I find it personally very helpful when we're kind of transitioning of care, giving sign up to a co-resident, a co-attending, or they're going from inpatient medicine to inpatient rehab. When do you feel like maybe this would be utilized? And I don't want to put you on the spot, but I know you, so I feel comfortable asking you. Totally fine, thank you. And maybe we can open up to anybody else. What do you think? The scale's got to be used someplace. At the time of admission? Sure. There you go. That'd be a great time to use it. So what you're going to end up seeing is that glasbicoma scale gets utilized as people are coming into the trauma unit. So you're going to ask them, hey, what was the GCS on admission? X, Y, and Z, okay? And so you can see here where a minor brain injury or a mild traumatic brain injury, also kind of synonymous with a concussion, the score is between 13 and 15, okay? Now it's hard to say, and this is just, I can't help myself from just giving you fun facts for rehab here, that when they talk about a moderate or severe brain injury, that's always not pathognomonic. What I mean by that is if you've got someone with a GCS of a nine, legally speaking, that wouldn't quantify them as of them having a moderate brain injury because it's going to be so much in flux and it only happens on admission. There's a variety of reasons why someone would have a moderate brain injury if they're just knocked out, you know, and they're still kind of coming to, and they're really in that concussed state, as you guys kind of can see on TV with some of those football players, right? But a mild brain injury, you know, with 13 to 15, that's one of the categories that a lot of the governing bodies use to diagnose a mild traumatic brain injury is a GCS of 13 to 15. And here's my question. Does a traumatic brain injury, a mild traumatic brain injury or a concussion, need to have radiographical findings on CT or MRI? I'm going to go with no. Okay, you are correct. So by virtue of a lot of these definitions, you know, a mild traumatic brain injury shouldn't really have any imaging findings, should not have any radiographical findings. What you'll find often is that patients that might have what you would consider a severe brain injury. I have a patient of mine who fell off a third story building and fell onto a car. And anyone who saw it would say, yep, that's a bad brain injury. His symptoms are all a very severe brain injury, but his imaging is all quote unquote normal, you know? So just be mindful. A mild traumatic brain injury, fun fact, does not need to have radiographical findings here. So let's move forward. We were all correct. Everyone who answered A plus, A plus effort here. So for a disorders of consciousness here, what is it kind of a unique thing here with a coma? You know, usually they're going to be unconscious. They're not going to be awake. They're not going to know what's going on. There's not going to be much spontaneous or stimulus arousal, no eye opening. But the most important thing, if you remember anything from today, is that a coma means that there's an absence of sleep-wake cycle on the EEG, okay? That is the most important thing if you go on your rotations. They're like, how do you know someone's in a coma? You go, boom, no sleep-wake cycle on your EEG. They'll give you a residency spot right on the, right there, just cancel everything else. So, now when you talk about a vegetative state and a minimally conscious state here, you can see that both of them are conscious. They're starting to wake up. What the difference is, is that a minimally conscious state, a person in a minimally conscious state, they can reproduce simple commands, okay? So you tell them to do something, they might be able to raise their hand within the realm of what they can do. Meaning, if they're plesiac on one side, we can't say that they can't follow simple commands on the weaker side. You obviously wanna check the other side. But it says inconsistent, right? So, let's say that Dante, I know he's gonna be presenting soon, he walks in there and he's like, yep, they're not following any commands, vegetative state. And I walk in there and they follow a little bit of commands. You're like, gosh, Dante, you liar. Who's right, who's wrong, what's happened here? Does it fulfill the criteria for minimally conscious state and what does that tell you about how you should do your exams? You should probably do it multiple times. Go. And who can help you cheat? Because here's my thing, right? As a student, you're going to be the person they're going to say, you know what, go in there every 30 minutes, ask them a simple command. You're gonna be like, ah, me. But one day you're going to be that resident that's going to get to tell people to do stuff. But you're going to realize there's a more efficient way. So who else can give you this information on the interdisciplinary team? Nursing. Nurse. Nurse. Who else? The med student who's been hanging out with him all the, all day. Yes. And the therapist. So so what I would tell you as a student, you can always counter, no one's going to ever make you do that. So that's just that. So that's, I hope I didn't scare anyone to not do PMR at Rush or anywhere else. But what you can do is your resident's going to be like, hey, can you go find the nurse and the therapist and find out how well they're doing in therapy, how well they're following commands, et cetera, et cetera. And then your job will be to kind of collect that information. But what they're asking for is if they're like, hey, we're trying to figure out what their disorders of consciousness is, you're going to have to know that definition. So you're going to say, well, were they following commands either, you know, very inconsistently? Because it's inconsistent. So it's going to be very, you know, it doesn't have to be all the time, right? Intelligible verbalization, you know, and that might take some time. They might be mumbling. And then all of a sudden, they're saying a couple of words that maybe once again, may not matter to the context of what's going on in the room. They might say waterfall. And we're like, we're in Chicago, there's no waterfall here. They could be hallucinating, but that's a verbalization, you know, some sort of purposeful, you know, behavior, you know, visual pursuit and some sort of response. Sometimes you've got to ask the family member, hey, when we put on audio or visual of a baby, you know, their grandson, grandchild, family, do they change? Is there some sort of emotional response, you know, because it may not be you. So once again, that interdisciplinary team has to expand to the family, right? And then, yeah, and so you can tell that person is at a, you know, somewhat of a lower functional level. Here's my question to you. You guys are all going into rehab, obviously all neurorehab, no sports, spine or pain here. It would be just like me. Would you, do you think someone in a minimally conscious state should or could go to acute inpatient rehab? Why or why not? We'll have Jonathan and Dante save their debate for later. So is there anyone who has a feeling, yay or nay, someone go for it and someone say absolutely not? No. You got to back it up, Clarissa. Why do you feel it's a no? Because one of the criteria is that you want to go to rehab and you're not able to communicate that. That's fair. I love your response. It's a patient centric. The patient has not consented to this, but I'll counter that with their surrogate decision maker says, I make all the decisions that I say yes to rehab. So now what do you say? And I would kind of add on the requirement to be doing three hours of therapy every day, five days out of the week for like insurance to cover it. Sure. Sure. Fair point. Let me add on another layer here. Let's say that they have real bad insurance and the insurance states we will not provide subacute because, you know, that would be the other option. We will provide zero subacute benefits. And so we'll provide acute inpatient rehab and we'll provide, you know, some limited services at home. And the hospital says, well, you've got to move them off the floor because this bed is very expensive. Now, what do you say? We could maybe say that we're not sure whether he's out of the weeds yet or not until we can get some sort of stability, because if he is kind of on and off in terms of his ability to communicate, we don't know if there's maybe a brain injury that's progressing right now or something like that. So for observation, it might be better for him to stay. Sure. I think that's a great point. You want to buy some time, you know, give it more time, or you might say maybe Dante and Jonathan want to make some recommendations about the nursing, right? There are things that we can do to allow this person to participate more. And that's rule number one with rehab. A lot of things that you'll realize is that there's no hard and fast rule with a lot of things. And there's a lot of art to it. And there's a lot of creativity to it. I know of physicians, myself included, where we've taken patients that seemingly coming out of a minimally conscious state at a low level due to a variety of issues. One might be, we think they're actually emerging. We think in two days they're going to do great. Or the insurance is really crummy and we feel terrible about their situation. We want to do everything we can. So if they go to a sub-acute facility, they're not going to languish and have a pressure ulcer and et cetera, et cetera. So there's a lot of gray area. So don't ever feel like there's a right and wrong answer. Of course, anything I say is of course correct on my rotation. So you'll listen to everything I say, which is a joke, I just take it seriously. Now, before Jonathan and Dante come with their stims, let's all think and brainstorm here. Let's say, you know, that last person who spoke, who was that? What was her name? Helen? Helen, thank you for bringing that up. You were saying, gosh, there could be something else going on here. And that's the reason why this person seems to be in a mentally conscious state. So as a group, let's start to brainstorm. What are other causes for someone to have a low arousal, low cognition after the brain injury in the context, well, in a brain injury? Before you start that stim, what are things that could be happening? You can do the chat or you can speak up. Either way is fine by me. Maybe polypharmacy. Love it. Polypharmacy. Okay. What else? SIADH, maybe. Absolutely. It could be some sodium dysregulation. Edward said infection. Absolutely. So, yeah, I think that's all I have to say for now, but thank you so much for your time. What do you guys typically? Say it again. Maybe a bleed. A bleed, yeah, could be something new intracranially. Absolutely. What other things? What do you all do during lecture, typically, after a big meal at lunchtime? Reactive hypoglycemia. Good. You know, I can tell you a story. When I was a med student, way back in the day, our anatomy lectures were on Tuesdays and Thursdays. And right after lunch, it would go from one to six. It was a ridiculously long lecture, and then we had to go to anatomy. So we'd grab lunch, and inevitably, I would fall asleep for a good two of the three hours of the lecture. Not smart, I'm not condoning that, but I'm just saying, could sleep deprivation contribute to this person's lethargy here? And how often do our patients sleep in the hospital? Very minimally, right? So our approach to the use of neurosims has to be in a holistic kind of manner. We want to look at everything. So you are correct. We want to look at our CMP and take a look. Is there a sodium dysregulation? Is there a LFT elevation that's causing hepatic encephalopathy, maybe renal dysfunction? Maybe that renal dysfunction is causing the polypharmacy because those meds aren't renally dosed. And now they're having a bad reaction to it. Maybe we're going to check our CBC, and we're going to check, is there a whopper of an infection? Maybe hemoglobin is super low. Maybe the platelets are low, and that's the sign that they're spontaneously bleeding. Check that CT scan. Is there something new that's going wrong? Maybe a UA. Maybe it's seizures. We're going to check an EEG, blood cultures or test x-ray. And the list goes on, right? And so we want to make sure that all those things are in a steady state before we decide upon some sort of stimulant here. So now our debate begins with two students here, Dante and Jonathan. So we want to think we've got this patient with a dissertive consciousness, and we've got a tool of different medications, whether it be imantadine, whether it's bromocriptine, we've got modafinil, we've got Ritalin, we might have Adderall. Those are some choices here, or Ambien I think we put on the list. So Dante, the floor is yours. Tell me and the group on what medication is going to allow this patient to go into a ketone patient rehab? So out of the three medications that I got, which were Adderall, imantadine, and bromocriptine, from the kind of research that I did, it seemed that patients that start at this and kind of referring back to our Ranchos Los Amigos scale, there's one study I found that if you take two patients and you put two TBI patients, one at a higher RLA scale than the other, the patient with the lower Ranchos Los Amigos scale, and they're both being treated with imantadine, the one at the lower RLA scale will take the same amount of time as the one starting at a higher scale to reach the same point in the rehab. So in terms of a lower level patient like this one, I think out of the ones I have, I would probably start them with imantadine. Great. And so everybody knows, if you haven't heard of imantadine, it's given out like candy on the rehab unit. I say that, you know, tongue in cheek, but it gets given the most commonly. So if you're on a rehab rotation and they're like, what should we use this stem? Just be like imantadine? Or but say with confidence, be like imantadine, right? No matter what situation is going on, people use it for a variety of reasons. Now imantadine was originally given for, you know, Parkinson's patients who were having dyskinesia. It's kind of helped smooth out their dyskinesias. If you see Michael J. Fox, when he was doing that commercial, he was moving around a lot. That's a sign of dyskinesias. And it's an NMDA receptor antagonist, which is what helps with the dyskinesias. But in this instance, we want to increase dopamine because low dopamine is what's contributing to some of the low arousal. So Dante's choice is it of imantadine impacts pre and post synaptic receptors and allow of dopamine and allows it to kind of go up higher. The study he's talking about is a very landmark study, at least in the rehab world. It was in the fun fact, New England Journal of Medicine. And they did that study and they found that imantadine was a great choice to kind of optimize people's recovery. Now, one of the things that they did, and I want is another kind of thing for you guys to think about is when you're reading studies, you know, you want to see what they actually looked at. So in that instance, they use the disability rating scale. OK, it's a very common scale used during research studies because it can be used in a variety of different settings, phone and everything else. And so in that instance, they found for patients with severe traumatic brain injuries, they got better from a DRS, a disability rating scale perspective. OK, other skills that I'm randomly mentioning because it may be on the quiz later as well, folks, is that does anyone know what the best scale is to look at how well people move from different levels of consciousness that maybe it could have been used in this study? OK, if you don't know, it's called the JFK coma recovery scale. And so that's another tool that you can use. So when you when you look at rehab studies, you might see the JFK coma recovery scale or you might see that disability rating scale. Anyways, so imagining is a choice that's on the board. Jonathan, what do you got? Sure. So I have three drugs in my toolbox, Ritalin, Ambien and Mudafinil. Ritalin and Mudafinil are both more of a stimulant, which isn't necessarily our patient has a pretty severe TBI. So we're looking to just get him to a higher level of consciousness. So I actually use Ambien. Paradoxically, it actually in cases of severe TBI can cause an increased level of consciousness and help bring the patient out of their vegetative state or near vegetative in this case. Cool. And out of curiosity, the choice for let's say someone want to use Mudafinil, you know, a patient, my patient's family might look up and say, gosh, why don't you use Mudafinil? It's a stimulant. You know, we want to stimulate this person awake. Do you think there's some room to kind of utilize that medication maybe? Sure. We can also add on Mudafinil. It usually isn't used in monotherapy, but additionally, yes, could easily be added on. Cool, cool. And just as a caveat with Ambien, which Ambien is the sleep medication that some people use and, you know, the black box warning of people sleepwalking, the study or the use of Ambien was in a small study. So you want to be careful because yeah. And so some of the clinicians you might see were like, Ambien, what are you talking about? That doesn't make any sense. And the study isn't strong. So it's a very small case report that showed some sort of improvement in that patient's arousal. So use that information with a caveat. So when you're under rotation, you want to say, hey, I read this. What do you think? And if the attending says, oh, that's a bunch of garbage, you can be like, yeah, me too. That's what I thought, too. But it's something interesting to take a look at. And Mudafinil is another possible choice as well. If someone has obstructive sleep apnea and that's the reason why they're a little bit tired on the rehab unit, it might be a good choice because we have a lot of patients that come over to rehab, but they're like, I'm so tired or they're like barely staying awake. But, you know, when they're awake, they're good. When they're asleep, they're not so good. Mudafinil will just, boom, keep them awake. The other reason why Mudafinil, you know, I like that choice is because it was studied in fighter pilots who are trying to stay awake when they're, I don't know if they're off to war when they studied it, but they studied it in fighter pilots and it showed some significant improvement in helping with them stay awake when they have some level of sleep deprivation. I might be misquoting that or extrapolating that. So, OK, it's a good start. Now, as we're talking about the lower level patient, does anyone have any thoughts, feelings or questions before we talk about that higher level patient? Now, let's let's flip the script here. Let's say that, you know, because they came over to your rehab unit, they've done an extraordinary job. The government pays you 10 million dollars on the caveat that you continue to work for the rest of your life so you don't get to live in a beach vacation. And this patient comes back and said they're an executive at their company and they're saying, well, I know I had a brain injury. I have some, you know, some headaches here and there and mood issues here and there. I have sleep-wake function here and there because after a brain injury, we're going to have a lot of somatic symptoms, whether it be pain complaints, bladder complaints, a whole spectrum of symptoms. But they're saying I came to you because I'm having trouble concentrating and I feel like my sleep-wake cycle is playing into this and my mood is playing into it because I have some depression. But I just need to concentrate just a little bit better so I can do my job and perform. Hold on one second. I'm going to do my lecture, yeah. False alarm. So Dante, I don't know if you went first last time. What do you think would be good for this person to be able to kind of focus and concentrate from the medications in your toolbox? Yeah, so from my toolbox, I think for this patient, I would probably go with Adderall. In terms of TBI patients, it seems like it's a good choice, especially for patients who have already were already taking Adderall for a previous ADHD diagnosis or something like that. But I think for this patient, just to kind of help them focus, I think Adderall would be a good adjunct of a therapy that they're also doing at the moment. Good. And just as an exercise, Adderall will impact or modulate norepinephrine and dopamine neurotransmitters. And so the cool thing about these kind of medications is that one, it helps improve dopamine. We talked about the arousal part, but also the norepinephrine from a mood perspective. So you might potentially get a positive effect from the mood part, maybe. But you know, mood is so multifactorial, that's an oversimplification. Jonathan, what do you got? So for my toolbox, I would choose Ritalin or methylphenidate, also a dopamine and dopamine agonist, so stimulant effects to get him going, back in focus. Also, if he regulates time, it can also help with the sleep-wake cycle. You could also consider the addition of modafinil. You would just need to be careful that you're not applying too many stimulants at the same time. Yeah, and you want to be careful of those side effects. So with Adderall, Adderall mixes amphetamine and dexamphetamine, which is Ritalin, is the brand name for the stimulant. So they're very, very similar, if not the same. And so the thing that you want to be mindful of with the use of Ritalin is the side effect profile, one, in terms of the impact on medication that you might take. So just be mindful of anti-epileptic medication. It actually prevents the breakdown of SSRIs. So if you take it with an SSRI, the SSRI will be more powerful, which might be good from a mood perspective, you know. Also, with an amphetamine of any sort, you're going to be worried about tachycardia and heart problems. It's a case-by-case basis. I had one time, I guess I was bugging the cardiologist too much about it. He's like, he retorted, I sent him a message, he said, OK, he's like, he can do jumping jacks for all I care, he's going to be fine. So, but of course, you know, if someone's got, you know, AFib and VTAC and all these other issues, you know, you might want to pause and ask the cardiologist, what do you think? Because every case is going to be different and you don't want to go rogue on these cases here. And at the end of the day, sorry, oh, sorry, is there time to ask a quick question about this? Oh, please, please ask questions. So with this, with the management of this condition with farm agents, is that a long term treatment or is it just short term? If this person is having trouble concentrating and everything now from an injury, do we expect them to get better eventually and not need the medication anymore? Because those drugs are, they have so many side effects. And yeah. No, fantastic question. You should always ask the question and you should always question what meds are actually working from a rehab perspective. And I say for one big reason is rehab docs, including myself, we like to pat ourselves in the back because we start in bed and then hallelujah, everything is changed for the better. But you never know. It's just a coincidence that something else happened, right, that allowed them to get better. So imantadine, you know, if you look at the study, there was a wash up period after the six week mark. And so I always encourage patients to really think, do you really feel that there's a cause and effect or have you missed a dose every once in a while? And what happened, you know? And, you know, and patients might come in and saying, well, do I really need to take this medication? So I always encourage them at the six week, six months or the one year mark, it's a time for us to really think, is this medication needed? And if they're unsure, I would say, let's just do a wash up, not a wash out period, but like a stop period. See what happens if they're at their high, you know, same level of function. I'm going to say, well, we really don't need this medication because it's not providing you any positive effect. And then if they notice something poor, then we can, you know, they're like, I can't concentrate or anything else. Then it's a reason for us to resume the medication. And then and I think, Helen, you're the one that was asked the question. The most important part is that, you know, we talked about two different types of patients, right? One was a low level patient who were trying to get participating in therapy. And the other person was that high level patient who, the high level patient who is an executive who is trying to focus. That person may not be may have been started on imantadine, but may have not necessarily outgrown it, but just may not be giving him the effect that they want. And so as they got to that higher level, we would switch. We'd say, well, you're on the imantadine. Do you think it's working? No. OK, let's discontinue it and let's try methamphetamide and or, you know, Ritalin or Adderall or whatever it is that they want to use. It might even be medical because that's what they research and they're saying that's what they want. I give my patients like most of the psychiatrists a lot of latitude. The only thing that I prefer not to do is that I don't like to do two stimulants at the same time, because, you know, if you're not getting an effect with one adding on another, you're just increasing your side effect profile. And so, you know, and a lot of times, you know, the biggest key for us is unfortunately, we're the people that have to talk about prognosis. And so, you know, the spinal cord docs, they have a very tough job talking about prognosis early on in the care and then moving forward. But brain injury as well, you know, when that executive is not doing as well as they should and we've tried everything, we might need to say, listen, this is a brain injury and we need to start thinking about what your maximum capacity and capabilities are and make adjustments accordingly to your life, you know. So any other questions? All right. Dr. Cossey, I have a question for you. Yeah, yeah. This is kind of a loaded question, but in terms of comorbidities that you might see, you know, you might expect like an increase in blood pressure, like you said, if you have a stimulant. Is there any other common comorbidity that you think is worth maybe mentioning, being mindful of when considering stimulants is something that you see a lot of times on the floor? Yeah, no, I think, you know, when we talk about imatidine, the biggest thing I worry about is hallucinations because too much dopamine creates hallucinations. And that's why we use antipsychotics that are anti-dopaminergic, I cannot say that word, but you know what I'm talking about. And so, you know, for a patient who's older with a poor creatinine clearance, we have to renally dose it. So the biggest side effect that I'm looking out for is hallucinations or too much agitation and then really looking out for creatinine clearance as we adjust it. With Ritalin and Adderall, I'm always concerned about the medications that they're on. I always have to refresh my pharmacology and just make sure it's not going to impact their medication that they're on. And so double check that. And then outside of cardiac, nothing to really worry about other than them feeling jittery, you know, and we're always good. I feel like physiatrists are always good about starting low and going slow and titrating up. I know I don't see other fields, but of course, we're the best. Right. So non-physiatrists, whoever they might be, sometimes they go a little bit more aggressive and then you see patients saying, like, I hate that medication, made me so jittery or, you know, whatever it might be. And then when you start low, they're like, oh, yeah, it's fine. You know, I did great with that med, you know. Awesome, thank you. There is this fun fact, we covered a couple of the questions, all favor and paid attention. OK. Any any questions, I want to give you guys a three minute break, so that'll take us to three. I'm on central standard time, so it'll be three twenty eight bathroom break or a water break, whatever you might need. And then Dr. Patton is going to be talking about specificity. Pay attention, everyone, when he does talk, because it's going to be all on the quiz. OK. All right. We'll see you in three minutes. Bye-bye. All right, so a short break, but if anybody needs to kind of come and go as they please they can. Andrew, do you want me to give you your introduction? Yeah, sure. Thank you. All right. I feel special now. So we're down to our last lecture before we do our quiz. So our speaker is going to be Dr. Andrew Patton, who is an assistant professor and the associate residency program director at Rush. I shouldn't be stuttering through, sorry, I shouldn't say that, I shouldn't be fumbling through that because he's in the room right next door. We are going to have him speak about an approach to specificity because he is a specificity expert. Dr. Patton, the floor is yours. All right. Well, thank you very much, Dr. Kassi. Happy to be here with all of you guys. We're going to go over this approach to specificity. So we'll go into some details about specific treatment options and each one will kind of have a different detail associated with it. But I really just wanted this to kind of be an overview of how maybe to organize your thoughts or approach this in a regimented manner, an organized manner, and kind of have a continuum for care when you're approaching or seeing a patient for specificity from whatever etiology it might be. So we're going to look at a couple of things today, including knowing what diagnoses to expect might precipitate specificity. So there are times where you might be seeing a patient for specificity consults or maybe for a different consult, I should say, let's say it's leg pain and it turns out that they had a spinal cord injury or a brain injury or a stroke or something a number of years ago and their leg pain is actually due to spasticity, but primary care or whoever sent you didn't quite recognize that as the cause of their pain. And so now you can kind of have in the back of your mind, oh, well, it makes sense they might have tone there. They had this diagnosis and so let's treat it accordingly. I also want to go over some positive and negative effects of spasticity. So to rate, I think some people also don't necessarily realize that there can be some positives from that. We'll look at timing of treatment and then, like I said, kind of build a continuum of management that you can use to help formulate your thoughts and hopefully make sure you're kind of working, ticking off all the boxes and covering all your bases. So when we talk about spasticity, you have to kind of understand what you're dealing with. And now, of course, there's not an established pathophysiology, so there's not one accepted definition of spasticity and depending on what source you read, you might read conjecture of multiple different etiologies, but it's really believed to be on a more macro level, if you will, a loss of descending facilitory inhibitory influences. So it's the inhibition that gets lost from whatever the neurological injury might be. So then you have kind of an overactivity of these reflex arcs or the muscle activity itself. Of course, again, you guys are probably very familiar with these diagnoses, but always important to kind of keep in the back of your mind what conditions might predispose somebody to developing spasticity or when you might expect to see it. So we're talking about upper motor neuron injuries, and that can include obviously stroke, CP, anoxic injuries, TBI, SCI, MS being another upper motor neuron syndrome disease. And then there's all sorts of other CNS neurodegenerative diseases where you can start to see this as well. I always want to touch on nomenclature because I really do think it's important and we have different words for a reason. And I don't want to use these interchangeably because by their definition, they're not. And so I just want to make sure that when you're using these types of things, and you'll see in medicine that not all even specialties or roles will use these words maybe in the way that they intend to. And so I just want to try to let everybody be on as similar a page as possible. So always know, and this is actually going to be on PM&R boards when you guys eventually get to that stage too. So knowing that spasticity is involuntary and velocity dependent. So that's key there. It's dependent on velocity. So the stretch of that actual muscle body that causes the increase in muscle tone. And it's obviously a component of upper motor neuron syndrome. Whereas contractures are a loss of active and passive range of motion. And that can be due to a number of things. Of course, prolonged positioning from spasticity, let's say, and untreated spasticity can result in a contracture of a limb, but they're not the same thing. So just making sure that you're using those words properly. There's a lot of times where I get a consult and in the order it says consult for contracture management. And while we do do that, I think when you read their note, what they meant was they meant spasticity and they were hoping to get the patient on Botox injections or something like that. So just knowing what you're dealing with. I think it's also important too when you're talking with the patient to explain the difference because a contracture is a permanent change to the muscle or around the joint, let's say. And so I have a lot of times where somebody maybe has had a contracture, an actual contracture, and maybe from spasticity for a number of years and they finally find their way to rehab clinic and they really want to try Botox to get it loosened up so that they can fit in an AFO again or whatever it might be. And you have to kind of break the news to them that contracture isn't going to get fixed with antispasmodic medications or toxin injections. And at that point it's, you know, you'd need like a surgical release or something like that. So always keeping those things as clear differences, clinical entities is important. So I'm sure that you guys have probably all to some extent been introduced to the modified Ashworth scale. So you know, I won't belabor the point here, but just understanding that there are different ways or different levels to grade it using this scale. It can be helpful because spasticity really is a difficult thing to objectify. And so this is our best way of being able to at least be all on the same page when we're describing the level of spasticity that you're seeing. It can also be really helpful for, let's say, intrarater measurements, because I can maybe judge somebody on their evaluation day and say that they have an MAS of two, and then I start baclofen and then they come in and now they're a one plus. So I can grade my treatment and understand that it's making benefit. And as you guys get into the wonderful world of insurance authorizations and getting medications cleared and paid for, it's going to be important to prove that your treatment is effective and showing benefit for them to keep paying for it, especially when it's expensive stuff like toxin or maybe nerve blocks or other things. So when we talk about complications, I think it's pretty straightforward. Everybody I think can recognize intuitively a lot of these things, which are the negative aspects that might come along with spasticity. It can obviously interfere with function. It can cause pain and discomfort at times. It can interfere with hygiene or nursing care. There's the risk of contracture, like I mentioned, and then, of course, there's the cosmetic side of disfigurement that some people find really distressing, the risk of ulcers and pressure sores, fractures, and that can be a really serious complication, especially in somebody who is maybe insensate below a certain level and can't tell that they had a fracture in that area. And then, of course, once it's present, it can be really hard to heal properly if there's a ton of muscle tone in that area because you're constantly pulling on that fracture area. It's hard to keep it well approximated. Dislocations and subluxations are a risk, and then heterotopic ossification or HO can also be a complication of this. But some things that I think maybe aren't intuitive are the benefits of spasticity and something that you should always consider, and I think if we're looking at this through the lens of how are you going to use this information that you learned today to really shine on your rotations and as a resident as well is to make sure that you're explaining the potential benefits of spasticity and that we don't want to take away any of the positives that the patient might be gaining from their increase in tone. It can help with ambulation or standing and even transfers, and here's a little picture animation of a stand pivot transfer, although she doesn't quite get to standing, but she might be utilizing tone in her lower extremities to help be a base of support to pivot on so that her caregiver can get her over to that table more easily, whereas maybe if she didn't have that increase in tone or maybe was over-treated with medications for it, that it would be too maybe flaccid for her to put weight through and would be more burden on the caregiver to get her over to that chair or that bench. It can help with maintaining muscle bulk in certain circumstances. There's actually research that shows that it might assist in reducing DVTs because you're having those muscle contractions with the spasticity that helps with that venous return and movement throughout the lower extremity. They have found that it can reduce the risk of DVT. And then if we all remember our Wolf's Law from medical school with the tissues responding to the forces that are placed upon it, it can prevent osteoporosis to some degree as well because your muscles obviously are attached via tendons and so that's pulling on those bones and so that can actually cause force to go through those bones and where maybe somebody isn't ambulating very well anymore, this is going to provide some resistance to that tissue to help build up the density. And then of course, I think you probably use this a lot as a diagnostic tool in clinic when somebody has an increase in their tone, instead of jumping right to, oh, we better increase your baclofen, we also need to ask the questions of, hey, do we have some kind of noxious stimuli that's causing like skin irritation or skin breakdown or something like that, restrictive clothing that might be causing this, do we have bowel impaction or an infection brewing, something like that that we might need to treat an underlying cause before we start adding on either additional treatment or other things. So moving on, oops, hold on, there we go. I always just say, let's stop and have some consideration in our treatment before we pull something out of the tool bag. So of course, always understand your indication for treatment. And I think that just the fact that it's present, isn't a good indication to start treatment for spasticity. Again, you want to look for potential benefits that they might be having from it before you just completely eliminate it and all of our treatments are going to have some level of side effects. So you always want to be weighing what kind of benefit they might get from this to any potential side effects or drawbacks. Understanding with the patient and their family is also really important when we're talking about expectations. This isn't going to be a cure for their weakness. This isn't going to be a total cure of their spasticity in a lot of cases. Really what you're trying to do is focus on what improvement are they looking for and then really focus your goals on that. We're not going to totally get rid of this problem likely. And then of course, too, that you're not going to improve their motor function with this in terms of increasing their strength. So getting rid of weakness, whichever way you want to say it. So I'll have some people that say they've had a stroke, let's say they're hemiplegic and they're coming for a consult for potential toxin injection to loosen up their arm a little bit. And they ask me, well, is this going to make me use my arm a little bit more to do more things with this arm? And it's a very carefully worded answer to that question because yes, you may be able to do more things with that arm if we get rid of the tone, but understand this isn't going to add strength to those muscles. So maybe they will gain strength depending on where they are in their continuum of rehab if it's still really early after their injury, but just letting them know that you're not injecting this to give them strength in their arm, it's simply to control the tone. And then of course, too, when you're trying to pick out which treatment or modality you're going to use, you want to think about the distribution of the spasticity. So are we talking about focal spasticity in one specific area or muscle group that you really want to target because that's where they're having their biggest deficit or their biggest problem? Are we talking about generalized, so all four limbs maybe, or really widespread? And then hemiplegia too. So when we're talking about certain interventions like maybe an intrathecal baclofen pump, which we'll talk about later, you have to take into consideration that one side is not affected by this while the other is, and so how we're going to balance that too can come into play. So I think a stepwise approach, as with a lot of things within physiatry, is an important aspect to this. And I also have a little caveat here of that when you're working through these steps to understand that not only can you work kind of down the ladder, and in a minute on the slides here on the upper right-hand corner, I'm going to have a little bit of an outline that we'll work through and it'll kind of help us stay on task or on base here. So in a second, that'll kind of pop up in the right-hand corner. But you can not only work through it in order, but also sometimes co-committantly, you might need to use two modalities at the same time. So we'll go into that a little bit. But looking at it kind of in this way, we're going to talk about avoiding triggers, of course. So you always want to eliminate the negative factors before you start a treatment, similar to what I mentioned with maybe underlying infection. You'll also want to start with some more conservative methods like stretching, range of motion, and other exercises. There's also splinting, casting, and other therapeutic modalities that a skilled therapist might employ that can be really helpful to avoid, again, medications or injections the patient might not even need if they utilize these other methods. Then, of course, we have our systemic medications, then local intervections like toxin or phenol injections, and then finally to surgical procedures that include rhizotomies, back-lifting pumps, and other things, which we'll kind of cover at the end. So moving on here, there we go. So we'll kind of keep, again, up in the right-hand side of the screen there, how we're going to work through this. So I always want to mention that prevention is a huge key here, not only at the beginning initiation of treatment, but also whenever you might need to evaluate for an increase or change in your treatment approach because the specificity might be getting worse or changing. So make sure that they know a good stretching regimen and a daily range of motion program. So hopefully they can do some of that themselves, but it might fall to a caregiver or a family member to also help them with this. And I think that that's an important part of utilizing therapy early on in the process to teach them these skills so that they can carry it on for the long term because specificity generally isn't going to go away over time. There are rare instances where it can improve to where it's not really detectable anymore, but generally they're going to be dealing with this for the long term. And so if they have these skills to be able to manage it on their own or their caregiver, then it really empowers them to have control over their own treatment and is kind of the bedrock for building upon that because if you're not doing these basic things, the higher level things aren't going to be as effective either. Always avoiding triggers, like I mentioned, infections, so making sure they know a good urinary program or skin protection program, addressing pain complaints is important, assessing for DVT every time that you see them, HO, like I mentioned before, heterotopic ossification and understanding the people that would be higher risk for that. Like I mentioned, urinary issues, skin breakdown, and then ingrown toenails and other kind of like noxious stimuli to the skin, especially in areas that are hard to sense for some people. Those are important to make sure that you're monitoring and teaching them, hey, this is an area you need to pay attention to going forward. And like I said, the patient and the family should all be actively involved in monitoring this stuff. So again, going over some physical modalities, some of this stuff can be done on their own and some of it can be done with a skilled therapist. So that includes stretching and splinting and casting potentially. There's hot and cold modalities that might be used. Of course, ergonomics and proper positioning is going to be another really big key player here. There are techniques like direct tendon pressure, FES, functional electronic stimulation. Those units can sometimes be really helpful and there are some payment plans and things like that because those units can kind of be pricey. Vibratory techniques, there's other relaxation techniques that can be learned through therapy and then motor reeducation, of course, is usually part of the whole like initial therapy as you're trying to build that motor strength back if possible. So motor reeducation too, though, for the spastic muscles can be really helpful and something they can do in the moment if they're having a really spastic moment, they can do some techniques to kind of calm that episode down. The next thing you might, after you feel like they've maximized the potential from those conservative techniques, looking at pharmacotherapy, it would be maybe the next logical step. There are right now really only four medications that are approved by the FDA for spasticity. Now this is not the same as muscle spasm. So there are musculoskeletal, you know, reasons for muscle spasm that there are other medications that are FDA approved for, but we're talking about the four that are for upper motor neuron, like spasticity, a variety of this. So that includes Baclofen, Tizanidine, Dantrolene, and Diazepam. You'll recognize that there are maybe medications you've used for spasticity that aren't on this list, and we'll touch on that in a minute. This is mostly good for mild to moderate spasticity. And again, better for a generalized approach versus focal. Now that's not to say that if they're really just like monoplegic in the arm, let's say, that you can't use a medication to try to help it, just recognize that you're gonna get systemic spread of this. And so if you have more of a generalized picture, an oral medication might be a better choice because you can affect all the limbs at the same time versus a targeted approach. These may be best, again, in SCI or MS. We'll go through a table here that I took from a review book where they'll specify specific ones that might be better for brain injury as well. And then again, it may be good for reducing tone and decreasing the amount of pain that they might feel from it, but there's not good studies to show that there's a functional improvement from using it. So that's also an interesting key to this. You may think like, oh, if you control tone, maybe they'd be functionally better. And maybe that's the case to a small degree, but this kind of goes back to that conversation maybe that you have at the beginning of treatment and that this isn't gonna give you motor function back. This isn't gonna add strength to a plegic arm, let's say, it's just going to control the tone. So these slides are really busy. So I'll just point out some highlights on here. This is taken from a really popular review book that you guys all will probably come across at some point, but I wanna just kind of lay out a couple of details for a few of these medications. So Baclofen being the first one we'll touch on, it's a GABA mimetic agent. So that's gonna target GABA-B. And I always remembered it as GABA-B is for Baclofen. And in remembering that GABA is the same receptor as alcohol and as a benzodiazepine. So we'll get to a benzo in a minute with Valium, but this is the GABA-B receptor versus the GABA-A, which is alcohol if you wanna remember it that way. And benzos act in that same vein. So this is providing some inhibitory effects. So if you remember to back to the beginning, the etiology being a loss of inhibition for the muscle. So this is adding on some inhibitory effects. So this is how it's helping the muscles relax and help with this reflex arc. Generally the side effects that you'll see with this is that it can cause sedation, drowsiness. Some people might feel a little bit loopy on it like they've had a couple of drinks. And again, we're talking about GABA receptors. So that can be common where they feel a little bit like they've had a couple of alcoholic drinks. An important thing to remember here, and this is definitely something that comes up on board exams for PMNR is that it can lower the seizure threshold. So that's something to keep into consideration when you're talking about brain injury, which again, kind of goes back to this next one over, this next category of the uses that spinal forms of spasticity are typically the first things you think about for this, again, because you don't want to lower that seizure threshold anymore in brain injury, but it's not to say that you can't use it in those situations, because we definitely do. Another important thing to remember about Baclofen is that you need to taper off once you get to a certain level, if they don't longer want to be on it, or you want to change treatment plans, if they suddenly stop Baclofen, similar to alcohol, you can go into withdrawal. And so you want to make sure that you're using this properly and educating the patient on, hey, don't let yourself run out of this medicine. It could be dangerous. Or if we want to stop it, I'll give you a taper plan. Don't just stop it and then come in the clinic later and tell me that we're going to do something else, because that could be a pretty serious situation. So the next two we'll talk about is diazepam or Valium, like I mentioned before, and then Dantrolene. So Valium is a facilitator of GABA-A receptor. So like I was just mentioning, that's kind of, it's the same receptor as alcohol. So that's why it's typically used in various protocols when people come in for alcohol withdrawal, similar to other benzodiazepines. It is sedating just like Baclofen is, and it can have some memory impairments. So this is one that we want to use cautiously in brain injury because we don't want to impair the cognitive recovery in these people. So we really like to kind of reserve it for spinal cord injury or MS, those types of things where we're talking about spinal causes of spasticity versus brain injury to not affect the cognitive piece to this. It can be used as a second agent. So as like an adjunct to maybe a Baclofen, like maybe you get up to a really good dose of Baclofen, but they can't go up much higher on there, and you want to add something on that's a little bit longer acting. So there's times where I use this as like a nighttime aid for somebody because of the sedation too. So maybe they're on a nice daytime dose that they can tolerate and still work or function okay, but then they have a lot of spasms at nighttime. So I'll add this on as like a bedtime agent, and it gives them nice coverage through the nighttime and helps control the nighttime spasms, which seem to be common. All right, and then when we talk about Dantrolene, that's kind of a unique medication in this category, and that's because it's the only non-centrally acting medication. So it acts peripherally actually at the sarcoplasmic reticulum. So it blocks the release of calcium into the sarcoplasmic reticulum. So if you remember back to your physiology class, so then that's basically limiting the, it raises the threshold for contraction of the muscle. So we're kind of tampening down that muscle activity to help give a little bit of inhibitory response to this. Now, this isn't used as much as the other ones. And one of the reasons for that is because there is this really low risk actually, it's 1%, and some studies have found it to be even lower than 1% risk of liver toxicity. But when it happens, it's really quick and it's pretty fulminant liver failure. That's not to say that you can't reverse it if you stop the medicine in time, but it can be tricky to do or catch, especially if you're starting this as an outpatient and maybe you're not following their labs really frequently. So it's important to counsel people on this. I don't want it to scare you from using it. We still use it, but it does require some lab draws. And so I always give people that caveat, like, hey, we're gonna have to get some LFTs before we start this so we know your baseline. And then we're gonna check it pretty frequently, maybe through the first period that you're using this. And then once we find a good steady dose and your LFTs are stable, then we can spread out the lab draws. And then anytime, excuse me, that we're gonna increase or change the dose, you need to check them again to make sure that they're responding appropriately and you're not getting a rise in those LFTs. So I think that just the burden of that tends to be a reason why people aren't starting this very frequently. But if you look at it, the side effects are really minimal in terms of the drowsiness and the, excuse me, the sedation. So that tends to be the rate-limiting step for using some of the other medications. So this could be a nice alternative to that, I think, if you just are able to get over the checking the liver enzymes and watching out for that. Again, in this uses category, that's why they like to use this in brain origins, like stroke or CP or head injuries, because you're not interfering with the central receptors. It's a peripherally acting medication. So that's one of the benefits of that. But certainly good to remember this because that will definitely be tested later, but also a unique aspect of that medication. So here are two other ones. I mentioned to Xanadine before as one that is FDA approved. I'm not gonna talk about Clonidine all that much because it's not FDA approved for this, but it is used for this. I feel like just anecdotally, it's more used in peeds than adults. And it's probably just because it doesn't have a lot of the associated side effects that like a Benzo in a kid is, like maybe not the best choice, but so I'm not gonna talk about all that much. Again, it has kind of the same side effects and issues that you might run across when you're using it for blood pressure control too, which it's like a third line agent. And just because of the hypotension and it has like a long half-life. So you can have this kind of like hangover effect from it in terms of really low blood pressures, even when you stop it. And so, and then you get rebound hypertension in cases. So it's a little bit trickier of an agent to use for spasticity. But Tizanidine is a commonly used one and that's working on the alpha-2 adrenergic receptors. So it's similar to Clonidine in that it's working on those adrenergic alpha-2 receptors. It can cause drowsiness and sedation with patients. So again, the typical theme here with a lot of these centrally acting medications for spasticity and there is, it's processed by the liver. So there is a potential for liver issues. And so it's one that when maybe on the inpatient that you might check a CMP or something every once in a while to make sure that the LFTs aren't increasing. So, like I said before, it's studied well with spasticity, the SCI and MS, and it can be really effective if used in the right patient. So definitely consider this. I typically just, again, anecdotally use this as kind of like a second or an adjunct, similar to the Valium where I like to go for the Baclofen first and then add this on spot doses if we need like a booster. It's working in a different way. It's not the GABA receptor. So there's not gonna be a lot of overlap there, but it is pretty drowsy or sedating, I should say. All right, so when we talk about other medications, now this is an exhaustive list, if you will, and we're not gonna go into all these, but I highlighted a couple of other ones that may be more familiar to you guys. So gabapentin can be used for spasticity. It's probably not the most effective, but a lot of these people are gonna need gabapentin for other reasons, maybe neuropathic pain. So you can get a little bit of double duty there with that. We talked about alpha-adrenergic blockers and GABA agonists. There are some anti-epileptics that can be used for this. Chlorpromazine can, ciproheptadiene, which again, I think, again, I don't use it. I know I've seen it occasionally when I've inherited patients who were following in a PEDS clinic and now they're in an adult clinic. So I think it's used on the PEDS side a little bit more. Flexeril is a popular one, not FDA approved for the upper motor neuron spasticity. It's not that you're ever gonna have a problem getting it approved or anything. I'm just saying it's technically more for the use for the musculoskeletal causes of muscle spasm, but it can be effective in certain patients. I was kind of surprised from basically here on down on the list when I was researching stuff for this PowerPoint when I was putting it together. Vincristine, which is a chemotherapeutic agent can be used, which is pretty crazy to think that you'd start chemo for spasticity. But I guess if they're already on it, maybe because they're getting treated for GBM or something like that, it could maybe be having a little bit of positive effect on your spasticity. Cannabinoids, I think, is something that's really popular these days. And we could go on a whole nother topic about the use of medical cannabis, but certainly people are using cannabis for this and can be extremely effective and can be really well tolerated with some people who really didn't do well with other medications. So definitely keep it on your radar and have it in your bag of tools. Morphine, glycine, and threonine are three other ones. Again, morphine, kind of wild that you would use that for spasticity, but it's on the list. So I wanted to make sure we mentioned it. Flexeril, like I mentioned before, acts at the brainstem level as opposed to the spinal cord level. And so that's why they think that in the spinal cord, it may contribute to overall skeletal muscle activity. So that's why, you know, you typically see it in like an MSK clinic or something where you have a more peripheral reason for their muscle spasms. But it's usually not the best one to kind of grab as your first go-to when you're talking about upper motor neuron causes. And then just as an aside here, cannabinoids. Technically, Marinol is the only FDA approved cannabinoid, and it's only approved as an anti-medic for chemotherapy, active chemotherapy, and then an appetite stimulant for AIDS. So if you use it as an outpatient or an inpatient, you can usually get away with it. But as an outpatient, if you wanna try to use this medicine, it's gonna be pretty expensive because you're not gonna get it covered unless they meet one of those two criteria. But medical cannabis has been showing a lot of promise. I think the problem is that we can't fund any good studies with federal dollars because it's still federally legal. So hopefully that changes in the next few years. But the strains and hybrids that tend to be higher in CBD and not as much THC usually are better with this. But again, there's a lot of overlap. And so, you know, kind of making a hard and fast rule is not a good way of approaching this, but just understanding that the balance between CBD higher versus THC tends to be a little bit better for the spasticity aspect of things. So then when you wanna move on past maybe a more global or systemic treatment, we look at local intervention. So we're talking about maybe you have a medication and it's just not quite attacking the problem well enough for you. And you really wanna get local and focal with this to get a good response, maybe in the hand or the foot or something like that. So this is when diagnostic nerve blocks, chemo, neurolysis, or botulinum toxins can be really helpful. So nerve blocks can actually be used for this. Basically a local anesthetic like lidocaine is injected around the nerve. And usually we use E-stem or people are now using ultrasound guidance a lot too to block the nerves and that can block it for a couple of hours. So that can be helpful for when you're planning things. So first of all, if you block, if you're having a trouble understanding whether somebody has spasticity versus if it's contracted, then you can do a local block. And if you can move them after that block, then you know it's spasticity. If they're still rigid after blocking that motor nerve, then you know it's not spasticity, they're contracted. And so probably your treatment for spasticity won't be as effective. But this can also be helpful for planning more permanent interventions like toxin or chemo, neurolysis, or even surgeries. Because if you block that nerve and they have improvement, then you're like, okay, now we know that's gonna work. It's kind of your diagnosis. And then you can move on to maybe a more lasting treatment since this only lasts a few hours. When we're talking about chemoneurolysis, this can block spasticity at a nerve for months to even years in certain cases. It actually causes demyelination and axonal destruction because it denatures the proteins. So you get axonal necrosis. So basically the reason why it takes so long to then come back is that that nerve tries to grow back. And sometimes it doesn't. So it can be permanent in certain cases, but eventually that nerve will grow back again and repair itself. And then that's when the spasticity comes in. Maybe you need to do a repeat injection, but it can last a pretty long time. You can do this within a trunk, like a motor nerve block, or you can use it right at a motor point where it attaches to the muscle if you really wanna be specific about what muscle you're trying to go for versus a group of muscles. Usually they use phenol or ethyl alcohol to denature these nerves. And complications usually is related to dysesthesia. So again, you're basically creating a nerve injury. And so you can then affect some sensory fibers. And so that can cause some dysesthesia in that area. It can also be pretty painful. So these are usually more painful than like a toxin injection. So that's one barrier. Some people find it completely unbearable and they don't wanna ever do it again. Some people are like, I'm only getting it once every year. Once every couple of years, I can tolerate it. It's really painful, but then it helps my specificity. So they say it's worth it. It can be permanent, like I said. So it can cause muscle weakness because you're blocking the motor nerve. You can have some local injection reactions, but then there's also these rare, but notable phenol can actually cause systemic reactions if it accidentally gets into the bloodstream. So you can have CNS depression or cardiovascular collapse. So that's pretty serious. Alcohol has little effect if it does get into you intravascularly. And if it does, it's basically like you just made somebody drunk for a little while because it's alcohol that gets in the bloodstream. And so they actually just feel like they're really drunk for a while and then it goes away and they maybe have a hangover and then you're in the clear. So generally not too serious of systemic effects with the alcohol injections. Now, when we talk about toxin, I think that's something that you guys are probably all familiar, maybe even done a couple in clinic. And this is used really frequently within our field and probably more widespread than the alcohol or phenol blocks. There's a lot of evidence-based medicine review showing the safety and the efficacy of this. There's seven serotypes of the clostridium botulinum toxin, A through G, type A and B are probably the most popular with A being the most with Botox, Xemin and Dysport. And then you also have myoblock, which is a B and then there's like a ton of other ones that are usually used like in more rare circumstances or for research. And as of 2019, so a couple of years ago, only the type A were approved for limb spasticity, but that's changing year by year. So updates are coming with that. They all work at the neuromuscular junction. So they block the presynaptic release of acetylcholine. So you're blocking that vesicle from docking and releasing the acetylcholine into the synaptic cleft so that thus you're reducing the signal transmission there, and then you're getting an inhibitory effect on those muscles. It starts working in about a week, but the peak effect is really after four to six weeks, and then it lasts for three months. And then by the end of the three months, you've cleared the toxin out of your system generally, and you have to redo the injections to keep up the effect that you get from them. Of course, side effects are pretty minimal, just injection site, like bruising, skin irritation. Sometimes you can get some nerve trauma if you get right on a motor point and you inject right next to a nerve. So you can get maybe some neuropraxia with that, pain and soreness, of course. And then if it gets in the bloodstream, you can have generalized weakness. So it's basically like giving them botulism, the classic disease syndrome. And so they can have dysphagia with that, respiratory muscle weakness and shortness of breath. I mean, if it's really serious and you get a lot of units, they might need respiratory support for that. But generally it's transient. It lasts a couple of days. They feel like they just can't get out of bed and they're short of breath. And then after about five, six days, they feel back to normal. But of course they didn't get it in their muscle. It went into their system. So they probably need an injection sooner than three months to get the actual spasticity effects. Now there is this theoretical potential for antibody formation. There's very few studies that have actually measured antibodies for the toxin and quantified this, but they have posited that there are some cases where you'll see people get a diminishing response to the same number of units injected of toxin. And so they're saying that this is probably an antibody against the toxin. So that's why it's not effective. And people are looking into that a little bit more, but it's kind of unclear how frequently this happens and what the actual maybe titers of the antibody would be. So there's not a clear, there's not, it's not routine to check for this or anything like that. So it's just basically, if you feel like it's not working as well anymore, maybe you can assume that they have antibodies, but it's not like you're gonna order that as a lab or anything. So when we talk about intrathecal treatments, we really usually think about baclofen pumps and these can be used for pain as well. So maybe in some of your pain rotations, you've seen this used for morphine or Dilaudid, but in this case, we're gonna talk about baclofen injected in the pump. This allows nice direct delivery right into the CSF. So we're gonna put this right into the central nervous system and you're gonna get a higher level or higher concentration of the drug. Really, you can get about a hundred to one ratio of the drug concentration. So you can really go high on this, especially for people who maybe were on baclofen orally and they really couldn't tolerate increasing the amount because it was so sedating, or maybe you maxed it out and they just weren't getting enough benefit. So this will really, you can ramp up the concentration there. It's nice because it's transdermally programmed. So you just put a little sensor over this pump that is in their lower abdomen. And then usually Bluetooth connects to an iPad or some type of tablet that you can then kind of adjust all the settings. And then the battery life, it can go about five years these days. And then motors are seven to 10 years, depending on how heavily these pumps are used. And they produce audible beeps when they're either low on medication, they're low on battery, or if there's some kind of malfunction. So sometimes they'll get like an MRI, which they're compatible with, but it'll shut it off. And then it'll make a little noise while it's restarting and stuff. They do need to be compliant patients though. So this isn't the one that you'll throw into somebody who's missing appointments a lot, or hard to track down, or hard to get to stay on a regimen because they're gonna need refills about every six months, sometimes more soon, sometimes a little bit longer, depending on how high their rate is. And there's a big risk for withdrawal if their pump runs out and they don't show up on time to get it refilled, or if their battery is running low and they don't schedule an appointment with the surgeon to get the battery replaced. You run a really high risk of having withdrawal, potential seizures. It can be pretty serious. Like I mentioned, they use it for other medications and other indications too, generally not managed by physiatry at that point though. So now I'll just briefly touch on these surgical treatments because we're not gonna be doing these generally. This is gonna be probably a neurosurgeon. And these are pretty intense, permanent, usually procedures. And so you really wanna make sure that you're selecting these people and sending them to the surgeon for evaluation by doing your due diligence and kind of working them up in all different aspects and maybe trying several different of these options that I mentioned before. But of course, we mentioned some orthopedic procedures that include tendon lengthening and tendon transfers when we're talking about contractures, or maybe you have a level of spasticity that you're treating okay, but because they're also contracted and you feel like if you can lengthen that tendon and then stay on top of their spasticity going forward, you would have a decreased risk of re-contracture then they might be a good candidate for a tendon lengthening to maybe fit in their AFOs or in their wheelchair better. Neurosurgical procedures include the pumps, like I mentioned, but also central electrical stimulators can sometimes be helpful for providing signals to the spinal cord to help with spasticity. Also rhizotomies, peripheral nerectomies, which is basically cutting the nerve and then chordotomies or myelotomies, which is basically where you're selecting out selective nerve roots and you're cutting the motor portions of it here. So this is where they would kind of dissect maybe a large nerve that has sensory and motor components and then you're gonna sever the motor component actually and it will result in a flaccid limb usually after that or at least in the muscles that are innervated by that muscle group or that nerve, I should say. But maybe that's better than the level of tone that they're having. So at that point, you're not gonna have that useful tone anymore, but maybe it was so much tone that you just need to get rid of the tone or maybe they weren't gonna be functional anyway. Let's say they have a significant cognitive deficits and if they were just limp, it would be so much easier for the caregiver to clean them or position them or prevent skin breakdown, then this is maybe a good option. So this is actually an intra-op picture of this exact thing here. So they pulled away some of these sensory fibers and now they're selecting out for the motor roots there to selectively ligate those and hopefully get rid of the spasticity. So in general, we talked about a lot of stuff today, but what I think is important is to always keep in the back of your mind common etiologies of spasticity so that you can anticipate and maybe monitor for the emergence so that you can stay ahead of it. Because as with almost anything else in medicine, if you can be proactive about treating this stuff, then it's easier to manage and maybe avoid some of the more serious and hard to treat complications that come along with it. So if you can stay ahead of the tone and anticipate when it might get bad or you might be able to get in there before it gets to a certain point, it's usually better. Also assessing the individual and what their circumstances are and what their personal triggers might be so that you can help decrease their spasticity and prevent them from having the increased tone in the first place. And then, like I mentioned before, evaluating the negative effects and the potential positives that they might not even realize they're getting from their tone before you go ahead and treat so that they don't lose some of the benefit if that's actually maybe bigger than they realized. And then generally moving from a more conservative to an invasive approach is best, but also recognize when you might need to jump to a more invasive or more interventional treatment because the spasticity is so bad or their pain is so bad and you just feel like this is really focal and doing the whole rigmarole of starting a medication and ramping it up and titrating it and then trying injections, let's go right to the nerve block or something like that. It might be helpful in certain circumstances. So always recognize that you're not gonna always be able to follow your same prescription every single time. And at the end of the day, as with anything else in physiatry, is always taking into account the patient's lifestyle and their choice. So just because it's there, and this has happened to me several times where I get a consult from another service, they come to my clinic and they say, well, I was referred here because they said I have spasticity. And so I don't know what that is. And they told me that I need to have it treated and they don't. And maybe it's not interfering with their life and yeah, maybe they have it, but it's not bothering them and they can do everything that they wanna do. And they're not having any risk factors for any negative side effects like skin breakdown or ADLs or anything like that. So I tell them, hey, this is what spasticity is. Here's what you can expect. I'm here if you want us to treat it, but if you're good, then I'm good too. And we don't need to start anything for this. And then you just kind of let that team know, like, hey, they're good, but thanks for looking out. And now we're plugged in with that patient. So complications arise in the future, we can be there to help them. Any specific questions? I'm gonna open up the chat here because I see that there was a question that came in a little bit ago. So it looks like here there was a question about using benefits of toxin versus alcohol. So there is more evidence-based medicine for toxin than there is alcohol or phenol, but there is a lot of evidence for those too. So they can be really helpful. I think the things, the benefits are that it's easily, more easily, I say, maybe reversible, it wears off quicker and it's more predictable. So if you do the injection with toxin, you pretty much know that in about three or four months, it's gonna go back to the way it was before if you don't do another injection. So there are some people who are a little bit wary of more permanent treatments for their spasticity because they're just not quite sure. And so that's sometimes how I pitched botulinum toxin is say, hey, let's try this because if you get benefit from it, then great, we can keep going with it. And if you don't like it, then we just don't do it again and you'll go back to the way that you are before we started generally. So, that can be a positive for some people that are waiting into this as their first treatment maybe. The other thing is that it's less painful in injection. So phenol and alcohol tend to be more painful when you do it and you generally don't run into the side effects with toxin that you do of alcohol that include potential permanent weakness or decrease in their tone, but also they may have dysesthesia. Like I said, it's sometimes quoted as high as 30%. So that's not negligible. So there is the potential that, yeah, my tone's better, but now I have crazy sensation through here or neuropathic pain. And that's generally not gonna happen with toxin as much as maybe phenol or alcohol. So always things to weigh. Of course, phenol and alcohol have their advantages too. So you just have to kind of weigh the pros and cons. The other thing to take into consideration is that you may not have somebody that does both in your group. You may not do both. I don't do alcohol phenol injections. I hope to learn, but that's not something that everybody gets trained on everywhere. It's kind of a specialty thing. And so you may not have those resources where you're practicing. So you have to go with toxin because it's the only option available. Any other questions? Yeah, Dr. Pat and I had a question. Sure. As a DO, have you been able, yourself personally, been able to use OMT or do you know other DOs that use OMT to treat spasticity specifically? And like, if so, kind of what are the indications and have you seen any benefit with that? Yeah, definitely. So I don't do a lot of like, let's say I don't have carved out time where I do treatment clinic with OMT, but I certainly use, A, I think the philosophy is just like, osteopathic philosophy is so in line with PM&R. It's crazy. And I think that's why there's so many DOs in physiatry to begin with. So those things align certainly. And I do use a lot of our diagnostic tools. And there are times where I do utilize small treatments, like maybe a little indirect or even some like muscle energy and things like that, like during my examinations or when I'm doing some of the treatments for this stuff, if I have kind of time and I'm kind of incorporating it in with my visit there. But yeah, I think that definitely it goes along with kind of the conservative management that I talked about before. So I think that when you're regulating that muscle tone and balancing the muscle activity, it kind of goes along with a lot of the different types of treatments that we have, including a lot of indirect treatments. But I think muscle energy sometimes too, as a more direct treatment can be helpful when you're activating those muscles, causing maybe a little spasticity, trying to trigger it, and then getting that relaxation and capitalizing on the relaxation of the muscle to kind of open up that range of motion and stuff too. So I think it's, and there are a lot of therapists out there actually that take courses in how to do OMT. And so I really like when I get a therapist that I know that I can refer directly to and say, hey, they have spasticity. I want you to do your normal kind of like, traditional approach to spasticity treatment as a PT, but also I want you to incorporate your osteopathic skills and do some treatments with them. They usually have a little bit more liberal schedules that allow for them to incorporate some of that stuff in, and it can be really helpful. Any other questions that I can help with? I have a question. Sure. You were mentioning that if somebody is in excruciating pain and it might be more localized, you might consider going straight to intervention. Do you ever get pushback from insurance for things like that? And like, how do you go about that? Very good question. And welcome to the world of our frustration with insurance companies. Yes. There are times where let's say, like actually there was a guy, a gentleman who is coming in. He was supposed to come today. He had to reschedule, but I was planning on injecting him with Botox today. And he has MS and he really only is affected in his right lower extremity. So he has a lot of plantar flexion tone, but outside of that, his tone is really well managed. And you can totally see it when he walks. He's plantar flexing like crazy and it's putting him off balance and he's catching his toe and he's at a high risk for falling. And he really can't fit in his AFO because he's got a lot of that tone there with the plantar flexion. So for him, he's tried Baclofen before and it made him drowsy on even really low dose. And I didn't even think it was a good choice anyway, but a lot of times I'll at least try medicine first because insurance will say, you have to try medicine. You have to fail two treatments before you can go to this. And it really is plan dependent. Now, a lot of the insurance plans take their cues from CMS, which is a center for Medicare and Medicaid services. So generally we just say Medicare rules. And so they will take their cues from that. And Medicare actually approves Botox or toxin. I don't wanna just be like heavily repping this brand of Botox because there's other choices, of course, and I do use the other brands too. But so when you're talking about toxin injection, there are indications for it being first-line treatment. And so there's a long list of approved diagnoses for that. And generally I don't have a problem when we're talking about those plans and wanting to go right to toxin instead. But it's some of the like private insurances or the replacement plans that are more sticklers where they're like, you need to fail two antispasmodics first. And then in those cases, sometimes you can write a letter of medical necessity and say, hey, that's not gonna be good for the patient by trying another centrally acting medication. Let's say we're putting them at a higher risk of altered mental status or falls or whatever it might be. And so this would actually be more detrimental versus if you let me do this local focal injection right in this area, then they get improved walking, less risk of fall, and they don't have all the side effects. And then I've gotten it overturned is just like administrative burden, which is kind of annoying. But yes, you will definitely run into some issues here and there. But I think if you can just make a good medical case for it, which I'm hoping that you're building in your mind anyway, when you're deciding what treatment you wanna use, then you will be able to get it approved. And generally we've gotten it covered at some point. Thank you. A lot of advocating for your patient, it seems. Oh yeah, for sure. But it's kind of nice in the sense that when I, I had to write a letter for this guy actually, like last week and send it to his insurance to get this approval. And it worked because, it wasn't that much extra work for me, because like I said, when you're working through this continuum of care and you're thinking about all these things already, and a lot of times I'm writing this in my note too, like to help justify everything I am thinking through, then all I needed to do was just kind of move it over into a letter to explain why I'm doing this. So it was things that you're already thinking about, it just is an extra step. But yeah, definitely advocacy is a big part of what we have to do. All right. I'll hand it back over to you, Dr. Cossey. I think you guys have some more programming today, right? Yep. Thank you, Dr. Patton. Great work. Great talk. So let us end with our quiz. I'm going to put in our, oh, I forgot to put in for everybody. This is our link. So once you get in the link, the code for the room is, oh, 320413. I will share my screen once everything, yep. And we will do them together. I can do them together. Hopefully everyone can see my screen and we can see how many people have joined. Oh, we're getting people to join. Good. Hopefully you realized when I said fun fact as I was talking, that meant that it was going to be on the quiz. But 15 questions, winner take all. Carly, how much are we giving away today? A hundred bucks? Are we giving more? You know, that's a great question. I think we were, yeah, I'm not sure. I think we were given the membership for sure. And then what did we get to for cash? Let's do a hundred bucks. All right, a hundred bucks. And so once everyone joins, how many people are on the lecture? There's 16 participants, so maybe 12 people. And let's see. All right, so I'm just reading there. All right, everyone answered. Let's see what the answer is. One plus, just so you know, the explanations are at the bottom, but Dr. Patton probably went over. He went over. Specificity, the upper motor neuron, upper motor lesion, so you remember one is catch and release. One plus is catch with continued tone for less than 50%. Two is when it's catch and continued tone for more than 50% of the range of motion. Once you start having restricted range of motion, it could be a three. And then if you can't move it at all, it could be a four. So we are doing well. All right, these ones should be easy. You have a B, B receptors. We'll go over them in a second, 3, 2, 1, fantastic, 100%. Next one is, what is a GABA-E receptor? Which medication is a GABA-E receptor? 3, 2, 1. The answer is thallium. We'll go over these in a second. This one modulates alpha-2 receptors. 3, 2, 1. Vanadine. And. 3, 2, 1. Answer is Botox. There we go. One of our fun facts discussed during lecture. Great. No acute findings. Hopefully you're able to look at the explanations as well. This one we did not talk about. This will be, I guess, whoever guesses it right or whoever read the article. Three, two, one, oh wow, we did good. Yeah, to just make sure that it's part of the secondary cascade that happens after a traumatic brain injury. It's one of the secondary mechanisms of injury and just that calcium influx just results in one of the contributing factors to cell death. Not very practical, unfortunately. Okay, I think we all got this right. Woohoo! 100%. 3, 2, 1. It should be vegetative state. I think that the big thing that we wanted you to capture is that when they start doing inconsistent, or when they start doing some level of purposeful activity is when they become more of a minimally conscious state. And I just put down the explanations for the vegetative versus minimally conscious state. And we talked a lot about the minimally conscious state. All right, I think we got this one. Woo-hoo, yep. Remember, it was the coma recovery scale. It's actually the JFK coma recovery scale. So if you go to the rehab center in JFK, this will be something that they utilize on the brain injury unit to really see where they are on the spectrum of a disorder of consciousness. The disability rating scale, if you remember, that was used a lot more for research in checking research measurables, so. It should be Ventral Pond. All right, hopefully the landmark study comment will jog some memories. It was imantadine. It's always gonna be controversial when you're talking about different disorders of consciousness and the best medication, but imantadine seems to be the one that's in vogue at this moment in time. Oh no, I forgot to go over this question, okay. Okay, so one of the things that you should be mindful of when you're in that sports setting, sorry, I forgot to tell you that I was clicking a button, is that second impact syndrome happens when you have a second concussive force within the first two weeks of the original injury. What ends up happening is more of a complex thing where there's a mechanism that is protected so the brain is not able to function. So you have unchecked cerebral hypertension and cerebral blood flow that results in cerebral edema. So that's why when a football player, it's more common in football players, when they get a concussion, they're assumed to have a concussion, they're more than likely not going to be playing that next week because the risk of that secondary, that second impact syndrome is high. And of course, those are the situations where someone gets a second impact that's not that severe and they end up passing away. So anyways, cool. Answered. I'll be above. All right. Okay, three, two, one. So one of the things about a traumatic brain injury, you are gonna notice a lot of headaches. And the most common ones should be either migraine or tension. Tension's a headache that you've all, I'm sure, experienced. It starts low during the morning, and then as the stress, everything else kind of picks up, your headaches will get worse. Usually in the front part of your head, you're like, oh my God, I'm so stressed out and I have a headache. Emotions can make headaches worse. All these supplements have been effective. And the main thing is just being mindful of, even a minimal amount of opiates, three times out of the week, can contribute to medication overuse headaches are called rebound headaches. So opiates are used, unfortunately, very commonly after traumatic brain injury, because people might have a broken shoulder, broken arm, broken neck, whatever it might be, and they're getting prescribed that medication in the setting of headaches. It's just hard. How do you treat one pain without acknowledging that it could be making your headaches actually worse? And that condition, what you'll notice is that patients will say, my headaches are getting progressively worse. The medications that you're giving me, the opiate, for example, was originally effective, but now it's becoming less effective, and I'm having more severe headaches when they're wearing off, and they want to increase the dosage because they feel that would be effective. And that's kind of the mnemonic for medication overuse headaches. And finally, Answer is false, and let me see who the winner is. Hold on one second. Hopefully it's... All right. We have one... Oh, nope. We have two people that tied. Adam German and Pooja both tied. So there can only be one winner, I guess. Let's do a number. Here, I'm gonna... I gotta write down a number. I'll write it down. I'll write it down on my hand. Hold on. Can't see here. Okay. It's a number between 1 and 99. So just put in the chat between the two of you. Okay. Adam has guessed 36. Pooja guessed 9. The number was... That must be a 1. So figured... Anyways. Okay. So Pooja, you win. Just... We will get your email. But just give me your... Just leave your email in the chat so I can grab it and email you the gift card, and we'll get you the free prize. Tomorrow, we will be doing this again. So money given out to whoever wants to join us. Just a couple of quick announcements for everybody. Thanks for joining. There is... Someone had asked about some of the TBI resources were difficult to access, because I guess the online access wasn't available through your school. We tried our best. It's just weird, because some articles are easy access through Google, and then other ones are through the library. And then even through the library, all the articles that I got, I wasn't able to access. Unfortunately, the easiest way is at your school. If you ask the library, they're going to be able to give you online access. They'll even let you download it. Just you're not allowed to share it. So if they give you free access, hold on to it. Download it and keep it in your file. I can show you. I have a Dropbox full of just all these articles that I have for myself for future research. But there's no easy way to do that. Dr. Pacheco wanted... Go ahead. Well, I was just going to say, for that same reason, we can't actually mail out the PDFs, because we can't share it. So unfortunately, we tried to do our best to make it easy for you, but unfortunately, we can't send the actual link, like the actual PDF to you. And also, another announcement, I think registration is still open. So if you guys want to invite friends that maybe haven't heard about the program for tomorrow, anybody's welcome. Sorry, go ahead, Robbie. No worries. And then Dr. Pacheco, who spoke in the beginning, said everyone is invited to the CNS Community Virtual Session, which is Thursday, October 13th. So about a month from now, we can give you a link to it. It's about intimate partner violence resulting in TBI and spinal cord injury. I'm assuming that she's involved with it. So I think it'll be a great topic for those interested in TBI. And then I think those are the main things. And I just want to add in one thing. I don't feel like... I feel like it's important, because it's important to me. As I was introducing Dr. Patton, as I was having... I just forgot what I was saying, so I wasn't kind of putting things together. I used the word stutter. And I want to just bring it up as an important topic for us to discuss, because it's important that we don't cavalierly, like I did, use a situation that someone might be dealing with in this kind of free-flowing discussion to make light of what... I was trying to be self-deprecating, but it could be triggering or negatively impactful for someone that's going through that condition. And we're all here, and I use that as a guide and an important teaching moment for all of us is that we're supposed to be disability advocates. And I say that's supposed to be because we're all learning and correcting ourselves as we make mistakes. And in the disability community, we want to be using person-first language, and some people like to use identity-first language. And then there's certain words that we don't want to use. One of the things that we don't want to do is be ableist. What that means is that we are assuming that our experience basically is the norm, and that it gets extended to different areas when we start to say, using a medical condition to use it as a joke, or we use it as a way to describe a situation that's occurring to us, but that's not really the true experience that we're experiencing. And I'm sure you've heard of people say, gosh, I'm so ADHD today, I can't concentrate. Well, you don't really have that. You don't really have that experience and the trauma and the experiences that that person that really does have that, and that's going to make that person who's experiencing it make it feel like, what are you talking about, right? So I wanted to, you know, I didn't, as I was saying it, I noticed it, I said, that's not a proper word, but I want to make sure I acknowledge it to all of you, that one, well, hopefully you accept my apology and anyone else that's hearing this on the recording accepts my apology for one. Two is that we're all works in progress. So, you know, as you make a mistake, own it, acknowledge it, and then hopefully in this instance, educate. And hopefully I don't do it again. But, you know, we all have a lot of the rehab group, you know, me, Carly, and some other physicians are all active on the disability advocacy community. So we can always come back and give you some teaching moments. Hopefully this was one of those, but anyways, thank you all for coming. Me and Carly are so happy that, you know, you all stick it, stick it, stick it to the end. And hopefully we'll see more of you tomorrow and then we'll be giving away some more prizes. So just pay attention. But I think tomorrow's gonna be really cool with spine and pain and some really good speakers. Okay. Thanks for coming, everybody. Thank you so much. Thank you very much. See you tomorrow. Thank you. Thank you. Candace, if you're still on. Carly, we just need to get. Oh, yeah. If you can just send me, Carly, I can take care of the price today. If you want to do the price tomorrow. And then Candace, if you can send me Pooja's email, that way I can send her the Amazon gift card. Yep. I already made myself a note. Thank you. All right, guys. Thank you so much. We'll see you tomorrow. Sounds great. All right. Thank you. Have a great night.

near stimulant medications

disorders of consciousness

Rancho Los Amigos scale

Glasgow Coma Scale

assessing alertness

consciousness levels

states of consciousness

interdisciplinary team

medications for spasticity

Diazepam

Dantrolene

Tizanidine

Baclofen

mechanisms of action

common side effects