All right, well, welcome, everybody. This is the Association of Academic Physiatry's Medical Student Council Journal Club. So we host these weekly, and students can sign up and present on whatever articles they choose. And we might give everyone maybe like one more minute. Looks like we still have some people joining in the waiting room here. And then we'll have Willie start first. Awesome. So he's doing, you can see his presentation up right now. He's going to be talking about foot orthoses. So just let everyone else join in, and then we'll start here in about a minute. And if everyone who's not presenting could just keep your mic muted and video off as they are, that would be awesome. Except Michelle, you're fine. Okay, looks like we've got about 14 people, so we can go ahead and get started. Waleed, whenever you're ready, go ahead. All right. Thanks, Christina. Thanks, everyone, for coming, and thanks to the Medical Student Council for organizing this and promoting the event. So as was already mentioned earlier, I'm talking about a review paper covering clinical outcomes for podortheosis used in lower limb injuries, both for prevention and for treatment. This was a fun experience for me, because I don't know much about the field of orthotics, and it's a very interdisciplinary field, as you might imagine. It involves biomaterials folks, biomechanists, physical therapists, and, of course, any prescribing healthcare worker. So there is a bit of a turf battle, but I think everyone has something to contribute. And my goal for everyone who's listening is that to come away, I think there'll be a lot of repetition of terminology, and there'll be a bit of a roller coaster ride if I take you through the literature. But I think, hopefully, everyone will walk away with a little bit more familiarity with the terminology, and then also a little more awareness of what we have left to find out with respect to the field. So the paper that I looked through was a paper by Patria Hume at the Alton University of Technology, and so it's a very nuanced paper that looks through a variety of papers covering foot orthoses and their clinical outcomes. And it is specific on the quality of the different studies, and the inclusion criteria is very strict as to the nature of the studies that are included. And it also is very particular about focusing on clinical outcomes. I think one common theme throughout this that we'll see is that foot orthoses induce a certain biomechanical effect, and then that will eventually introduce a clinical outcome. Today, the data that we'll be looking at mainly focuses on clinical outcomes, but it's important to remember throughout that there is a biomechanical adjustment happening in between. And generally, we don't understand that too well just yet. So in terms of defining foot orthoses, there is no universal definition, but some of what you might see in what I'm quoting from the paper itself is that it's a medical device employed to support and align the foot to prevent or correct foot deformities or to improve the functions of the foot. So much of what we'll be looking at today is a combination of prevention and treatment. And the materials, if you're interested in biomaterials, there is no shortage of materials that can be used, polypropylene, polyethylene, so various polymer plastics, acrylic, quartz, neoprene, fiberglass, carbon fiber composites, and then softer materials like ethylene vinyl acetate. And this is very important because the material confers specific mechanical properties that can influence both the performance of the orthosis and the comfort experience for the user. And then clinical descriptors you might see on the market include accommodative, functional, off-the-shelf, prefabricated, prescription, and functional. So again, I introduced this so that everyone is exposed to the terminology, and I won't say that you'll walk away from here knowing what all of these mean. You'll actually still come away with a lot more questions than answers, but I think the exposure is still good when it comes to knowing what's best for our patients. So the biomechanics of foot orthoses are poorly understood, but they're important to continue to try to understand because, like I mentioned, they bridge the gap between the material properties of the devices and the ultimate clinical outcomes. So as you might imagine from a physics standpoint, the general model is that the devices are pushing up against the foot to support the arch, especially as it collapses under load bearing. The one thing which I really want to emphasize is that the casting methods of the orthoses for customized ones can be designed in different ways. You might imagine a foot arch that is completely non-weight bearing will have a certain conformation, while one that is actually weight bearing will have a very different conformation of the arch. And so you can design an orthosis to take the form of a foot that is either completely non-weight bearing or one that is partially weight bearing, and the benefit or the outcome that that might have on the user is very different in those two different designs. And so whether you want to catch the arch before it bears any load or catch it when it's half weight bearing is a very critical consideration to take during the design of an orthosis. So ultimately, you're altering gait kinematics to increase efficiency. This could be athletic performance. This could be just everyday walking and standing for someone who's at work and wants a little more comfort or relief from pain. And so, as I alluded to earlier, there's a whole range of types of orthoses. You can look at prefabricated versus customized. These two terms I want to really emphasize before we delve into the literature, because I will, you will see them over and over again. The general takeaway is that prefabricated or over the counter, they're inexpensive, they're non-specific, whereas customized, you're contouring to the impression of the user's foot. And as I mentioned, you can either put it in a neutral position or under partial weight bearing. And that conformity will be based on what kind of outcome you want for the user. And with respect to material properties, it can be anywhere from soft to rigid. Rigid is a bit of a controversial term amongst podiatrists because they will argue that there's no such thing as truly rigid. Every material will have some sort of give or bend or a durometer reading, but these are terms that you'll often see and that we'll see a lot today through the review. This specific paper focused on three injuries of interest, and these are injuries that if you're a runner, then you'll be particularly familiar with, but they can apply to people who are not even athletes. Plantar fasciitis is a condition that can affect adults who are sedentary or active. It does affect about 10% of runners, but it is described as localized inflammation of the plantar fascia at the anatomical insertion on the calcaneus. There are many risk factors, and the etiology is a little bit controversial. I included in that bottom row search terms that this group used in the review of the literature. Tibial stress fractures are more commonly seen in long-distance runners, military recruits, and patients ages 18 to 28. This characterizes an overuse syndrome with localized inflammation around the bones. So you can imagine with a combination of high repetitive loads and suboptimal mechanics, you might develop a stress fracture. And then finally, patellofemoral pain syndrome. This is my favorite because it's sort of the most ambiguous. It's characterized as general pain and swelling at the front of the knee. There is a strong association with weakness in the VMO, and it will often be exacerbated or brought about with stair climbing, with running, with cycling. The etiology here is very controversial too. So you might be looking at malalignment, prior trauma, overuse. And then there's extensive conversation now about, is the defect that causes PFPS not actually at the knee? For example, could it be excessive pronation at the foot? And this is a common trend with a lot of injuries where the location of the pain may not actually be the site of the defect or the mechanical deformity. I should also mention with tibial stress fractures, most commonly they occur on the medial border of the tibia, but they can also occur at the lateral border on the lower third of the fibula or the calcaneus. So with respect to outcome measures that this paper looked at for studies, you could characterize them, as you might imagine, by either continuous or count-based measurements. So continuous ones are generally scales that patients use to characterize their pain, feelings of, or their observations of swelling and stiffness. One common questionnaire that I want to highlight is the FHSQ, or the Full Output Health Status Questionnaire, which was more function-focused. And so it was a combination of pain, function, what footwear the user was using, and their general foot health. And if anyone has more questions on that, I have a little bit more detail in the questionnaire in the supplementary part of the presentation. And the way that this review paper created a mode for comparison for all the papers that looked at was a Cohen scale to compartmentalize the results as trivial, small, moderate, or large effect sizes. Now, with respect to count outcomes, of course, these are more incremental than they are continuous. And so you're looking at successive treatment, how many patients perceived an improvement in their condition, was the final assessment positive, and especially military recruits, how many days were they off duty for their activity? And then you're looking at injury prevalence. Shin splints can be used interchangeably with PTSS, which is posterior tibial stress syndrome. And again, with military recruits, withdrawal from training is a pretty useful metric for the effectiveness of the devices. And then for studies that are controlled, you can have mechanical or non-mechanical controls. So the mechanical ones can be various orthoses that can be soft, customized shams, or prefabricated soft. Generally, the takeaway is that they are soft inserts or soft insoles. And then the non-mechanical interventions, you can have anti-inflammatories, including NSAIDs, and prescribed stretching programs. This figure you see on the right is from one particular study in the review, and these instructions for soleus stretching and Achilles stretching were given to all of the patients in the study. And then there are also uncontrolled studies that are included in the review. As you might imagine, these tend to overestimate the effect of the interventions. So most commonly, you can think of, aside from the placebo effect, the Hawthorne effect, which it tends to show, which is described as a change in user behavior over the course of the study after enrollment. So these are things to keep in mind, but we don't necessarily completely discredit the value of these studies. But it's just considerations to bear in mind as we look at the data. So I'm going to go through each of the three conditions that I mentioned earlier, starting with plantar fasciitis. So I'll start with Dr. Lynch's group at Texas A&M back in 1998. And this was a study that looked at count outcomes. So we're looking at final assessment of positive outcomes and treatment success. And so general takeaway for this is that prefabricated, rigid foot orthoses showed a moderate benefit versus NSAIDs. And so this is just to review when I use the words moderate or small or trivial or large, referring to that Cohen scale earlier. So the Lynch study had a moderate benefit for prefabricated rigid foot orthoses. The Pfeffer study, the Pfeffer study was the one I showed earlier that had a stretch group. This was a particularly interesting study because it had five cohorts within it, split among the 236 patients. This was particularly useful because it quantified improvement by group on a continuous pain scale. So you can actually compare the different orthoses materials. And all of these involved stretching, but there was a stretch only cohort as well. And so it was, are you stretching with a device or are you just stretching alone? And this is interesting because the prefabricated devices, which as you might imagine, cost significantly less, had the best outcomes. And you can argue a moderate or small clinical decrease in benefit with the customized devices as compared to stretching only. And finally, this study by Carl Landorf at La Trobe University in Melbourne looked at both prefabricated and customized semi-rigid foot orthoses versus shims. And these showed small to moderate benefits in foot pain and function at three months. And I'm just going to include the uncontrolled studies as well. General themes for these is that they showed moderate to large benefits in general. The Martin study that you see at the top is interesting because it didn't have a control group, again, uncontrolled studies. But all three of these groups, prefabricated foot orthoses, rigid foot orthoses, and a non-foot orthosis group. This is tension night splints, which are splints that keep the foot dorsiflexed at five degrees through the night, all decreased first step pain and daytime pain. So those were continuous outcome measures. The GROSS study in 2002 showed a moderate benefit for walking-associated pain. And then this last study as well showed prefabricated and customized, both having positive outcomes for plantar fasciitis-associated pain and function restoration. And so the conclusion of that study was it was an effective first-line treatment. If that's a bunch of words out for you, the general takeaway from the controlled and uncontrolled studies for plantar fasciitis is that there doesn't seem to be a whole lot of critical dependence on what type of device you're using. The general takeaway is that both prefabricated and customized tend to produce positive outcomes as compared to simply stretching or anti-inflammatories. Now, patellofemoral pain is a vastly different story. First of all, there's not much literature, or at the time of this review, there was not much literature, that would be classified as quality trials by the review group. The one that I would highlight is this one by Amal Saxena and Jack Haddad, which was a retrospective study of 100 patients. And this was perhaps the best endorsement there was of a photorethosis for patellofemoral pain, but it was that there was a small benefit with soft prefabricated photorethosis. So, there wasn't much more that was encouraging beyond this, to be honest. And so, unlike plantar fasciitis, where we see a pretty strong endorsement, the evidence is fairly weak for photorethosis use in patellofemoral pain. This last study, I didn't put these in chronological order because this last study's focus was actually primarily the next part that we'll focus on, which is tibial stress fractures, but they did also look at prevention of patellofemoral pain. So, whereas the first two conditions we looked at were mainly focused on treatment, a little bit of prevention, but mostly treatment, this last study group, as you might imagine, with tibial stress fractures, were looking for photorethosis benefit for preventing stress fractures. So, I'm going to lay these all out. Again, a lot of text here. The general themes for these five studies is that all of the groups involved, military recruits, military trainees, infantry recruits, not athletes. So, for a sports medicine journal with a group that focuses on sports medicine, this was not ideal for their objective, but tibial stress fracture prevention studies at the time, the literature was mainly available for military recruits. General structure for a lot of these studies is that there would be a training program, and any time that the trainees would report to an injury clinic, the data would be collected, and in many of these, they were using their standard infantry boots with or without the orthosis insertions. The Milgram study, which you see at the top, also looked at a reduction in femoral metatarsal stress fracture, and the other thing which I want to point out is at the bottom, the Feinstone group looked at several different types of orthoses, but you'll see that the soft prefabricated group had the most comfortable orthoses, or the users described a most comfortable experience, but fewer users finished the training. So this is sort of the paradox of orthosis use, which is that you would want to focus both on user comfort as well as improvement of performance and prevention of injury. General takeaway, though, with respect to tibial stress factor prevention is that several of these worked, that they were generally successful in reducing injury as compared to the complete absence of any sort of inserts in the infantry boots. So the caveat, as I mentioned earlier, it should be noted that the outcomes from military studies cannot represent the general sports population. And so at the time, there was a call for more work to be done on particularly long distance runners. So we went through the three conditions. If you didn't follow any of that, then hopefully this slide helps, and I apologize for any lack of clarity there. With respect to plantar fasciitis treatment, generally my takeaway and the takeaway of the paper is that there isn't a whole lot of critical dependence on what you're using. Customized semi-rigid and rigid foot orthoses have moderate benefit. This was shown by three studies, and one study showed that prefabricated semi-rigid also had a moderate benefit as compared to shams. With respect to tibial stress factor prevention, the customized rigid foot orthoses had a large benefit in reducing shin splints, or PCSS, which is posterior tibial stress syndrome. And the prefabricated soft foot orthoses had a moderate benefit versus insoles. Again, with pseudofemoral pain syndrome treatment, there is very poor evidence of a moderate benefit. And so the ground is a little bit shakier there. I'm going to take some direct quote bites from the discussion because I thought there were some salient points made here, and I'll just read it word for word. So since foot orthoses come in many types with different intended functions, it is important that healthcare professionals understand the basic definition of foot orthoses. And the weak conclusions about the use of foot orthoses shown in the study for most injury groups may be primarily due to the fact that the mechanical characteristics of the orthotics and not the functional kinematics and EMG produced by these interventions were used as criterion in these studies. There were some confounders, or possible confounders, across these studies, including the fact that we're focused on the mechanical and material properties of the orthoses, but we don't know much about our foot type, arch type, type of activity, and footwear. And this is critical because if you're looking specifically at the device but not the shoe that the user is wearing or what their gait kinematics are, then you have a very small portion of the picture. As I mentioned earlier, military studies are useful because there are so many of them, but for a sports population, there's a bit of a disconnect, and so we want information on both of those populations. And as I mentioned in the last slide, there's that middle ground that we don't know much about. So we have the material design and we have the clinical outcomes. Ideally we would know what sort of biomechanics we're inducing, and so are we improving the neuromuscular feedback for the patient? Are we improving the structure of the arch during the gait cycle? These are questions that are sort of up in the air as we talk about how the materials being used for these foot orthoses are producing certain clinical outcomes. So what are the takeaways that we want? So again, some direct quotes from the paper, which I thought were very well written. Healthcare professionals should administer foot orthoses with a specific functional kinematic kinetic and or muscle activity goal in mind. Based on recent evidence, a healthcare professional or biomechanist is not able to predict the kinematics, kinetics, and or EMG outcomes produced through a foot orthosis intervention. Therefore, biomechanists and healthcare professionals should work together to verify that the functional goal of the intervention is achieved with the prescribed FO. So what might that look like? Well, you know, we see that some of the papers in the review recommend certain foot orthoses as first-line use. But with specific MSK training, you might have mentioned that a short follow-up after an initial prescription of a foot orthosis can be used to confirm that the specific kinematic outcomes that we might want for a patient are actually there. And if they're not there, then we can perhaps intervene and offer a replacement before waiting for the ultimate outcome, and it can possibly save time and perhaps even money. I thought this was kind of cool. So in the time since 2008, there are several papers, and I wanted to highlight the titles just to kind of show where the research is headed. So this specific paper was focused on the relationship between devices and clinical outcomes. The other key papers focused on foot stroke patterns and injury rates on patients with pronation patterns and how they respond to customized foot orthoses, the effect of hip strength and how that might affect patellofemoral pain, and then also directed patellotaping for reducing patellofemoral pain. And so the patellofemoral pain is particularly interesting because the orthoses didn't show too much encouraging data, but there is definitely room for addressing what is a very common incidence of knee pain in athletes and otherwise through other interventions, taping or simply strengthening certain muscles along the posterior and inferior chain. And I thought this one quote was also really brilliant from that first paper that's on the list. Runners and researchers alike may profit from paying more attention to how people run than what is on their feet. So with that, I'm happy to take questions. I thought this paper of Kipchoge from his sub-two-hour attempt was great because it shows all the runners in different phases of the gait cycle. And so if you're a running geek, I think it's a brilliant picture, but I'd love to take questions or chat a little bit more to the extent that I can. I have a question. How come military recruits, why are there so many studies in that population, I guess? My guess is recruitment is easier. I think everyone's in one place and you have a nearby health clinic that can quickly assess and also probably is an easier time motivating folks to take part in the study. So that would be my guess, and I think it proves handy, especially given that the shoes probably are not optimal for general health of the foot. And so I think it provides an interesting opportunity for learning about clinical outcomes. I was wondering too, I saw one of your early on slides, you referenced a podiatry article and I was just curious, I don't know if you know this from this article at all, but how podiatry and PMNR interplay in the foot orthoses world. I don't know. I don't know if it's a turf battle or if it's a cordial relationship, so to determine. Okay, I didn't know if the article you did was specifically on podiatry. Well, so the interesting thing is that specific website has, oh, I'm sorry, I don't know if I caught you off there. No, no, it's all good. So the interesting thing about that website is that there's a good chunk of literature specifically on just the biomaterials of the orthoses. And so I guess not surprisingly, they know their field better than we ever could. And so I think there's a lot to benefit from with respect to how much they know about the material design and the intended clinical outcomes. Okay. We also got a question in the chat from Marjorie. In regards to the outcome for plantar fasciitis, what do you mean by semi-rigid customized? Are those the ones people get from podiatrists? Is there a specific material that was preferred? Great question, I don't know. So semi-rigid and customized are, so customized is that delineation between customized or prefabricated, or the customized is tailored to the foot of the patient. And then semi-rigid, this is, again, that controversial spectrum of materials, because what some podiatrists might call rigid, others might call semi-rigid. I think generally polypropylenes, quarks, some carbon fiber materials might fall under semi-rigid, but I don't know for that specific case what it was. And they may or may not be from podiatrists. Podiatrists are a common source, but not the only ones. And the materials, I also don't have a great answer for you, but happy to chat more offline. Any other questions? Awesome. Well, great job, Waleed. And just so everybody knows, he's a second year medical student from Boston University. Is that right? That's correct. Perfect. All right. Well, great job. That was really, really impressive. And thank you for sharing that all with us. Thank you. All right. And next we have Michelle. And Michelle is a second year medical student from Creighton. And she's going to be talking about her experience with pediatrics. And she's going to be talking about cancer pain management. We'll see her slides shortly here. Here we go. Hi, everyone. So my name is Michelle. I, as Christina said, I'm a second year at Creighton. And this is my first journal club presentation. So I'm excited to be here with you guys. And today, I'm going to just be talking about why movement matters in colorectal cancer survivorship. And I thought this would be an interesting topic because I just finished my GI block. And so it was kind of relevant. And it's pretty well known that physical activity can prevent a lot of diseases in the general population. But there is not as much research on the benefits of colorectal cancer benefits for colorectal cancer patients during and after treatment. And so I just wanted to explore that a little bit. And just for a quick little review of colorectal cancer, for those of us that maybe haven't reviewed GI in a while, it is the third most common cancer in the world. And it is the most common malignancy of the GI tract. It is pretty prevalent. So 1 in 23 men and 1 in 25 women are at risk in the United States. And some risk factors, the first few being modifiable risk factors, low fiber intake can lead to bacteria not getting enough carbs. And so they start to ferment proteins that lead to toxic compounds. And that can stay in your GI tract and mutate, causing cancer. Other risk factors include high intake of refined carbs and fat, obesity, alcohol, smoking, irritable bowel disease that can lead to constant mutations, as well as a family history or an inherited syndrome, for example, Lynch syndrome. And I threw in a picture of Dr. Henry Lynch because he was actually a Creighton professor and did a lot of work on Lynch syndrome. And at Creighton, we hear about Dr. Lynch all the time. And so I just thought that'd be kind of fun to throw in a picture of him. And some protective factors for colorectal cancer, aspirin is chemoprotective. Colonoscopy screenings, and then being able to limit any modifiable risk factors that I just talked about. So the article that I am discussing today was a meta-analysis, and it talked about quite a few different articles that I'm going to try and just summarize for you guys and basically go through why physical activity has been demonstrated to lower colon cancer incidence and recurrence and improve quality of life. I'm going to go through the biological mechanisms for this benefit. For example, inflammatory and insulin-like growth factors. Also be talking about some barriers to physical activity that a lot of patients face, some current intervention studies, and some potential future research directions. And I think it's important to start off just with the definition of colorectal cancer survivorship. And it begins at diagnosis and continues throughout life. And because of this, you have the possibility of second cancers and as well as long-term effects of treatment. And a lot of past research has focused primarily on early survivorship and quality of life rather than long-term health outcomes and disease prevention. And so that's what this meta-analysis was trying to focus on. So some issues surrounding survivorship. So it is great that improvements in screening and therapy have increased the overall five-year survival rate for colorectal cancer. The article cited 51% in 1975 and has increased to 66% in 2006. But given that there is improved survival, that means that long-term survivors are now at risk for other primary colorectal cancers or a primary cancer of another type, such as breast, prostate, or lung cancer. In addition, 80% of survivors report at least one comorbidity, the most common being cardiovascular, musculoskeletal problems, lung problems, and depression. And though survivors generally reported an excellent quality of life, their diagnosis could still negatively affect their function, their functional and social well-being. For example, fatigue, physical discomfort, negative body image, and physical limitations, these all can affect, can all persist for years after a diagnosis. As well as some patients could develop a sensory neuropathy due to oxaliplatin-based adjuvant therapy, which is a common colorectal cancer treatment. And 32% of long-term survivors reported limitations in just their daily usual activities due to these comorbid conditions. So, the article next talked about the current recommendations that are out there for physical activity. That's a picture of RBG, who was diagnosed with colon cancer and metastasized, and she also had pancreatic and lung cancer, I believe. She is a survivor and participated in physical activity throughout her life and was able to do a lot of work still in the Supreme Court. So, anyways, I just thought that would be a good little picture to share. And so, she was diagnosed with pancreatic and lung cancer, and metastasized, and metastasized It promotes a program encompassing endurance and resistance training during active treatment as well as post-treatment to combat any cancer-related fatigue. The American Cancer Society encourages feasible and safe physical activity to enhance quality of life and functional wellbeing, as well as to help prevent any comorbid conditions. The American College of Sports Medicine also recommends 150 minutes of moderate or 75 minutes of vigorous exercise per week along with stretching. And the article just stressed that any development of any exercise program needs to take into account the person's pre-diagnosis fitness level, understand that patient's treatment sequelae as well as incorporate an evaluation of any comorbid conditions that might be present. And basically any exercise program for a colorectal cancer patient should be pretty individualized. And so the benefits of moving in the general population I think is pretty talked about a lot, but there are also huge benefits of moving in cancer populations, which I don't think is as discussed. And past studies have shown that activity was safe during and after cancer treatment and led to improved strength, mood, anxiety, self-esteem, body image, and fatigue in both on-treatment and post-treatment phases. And then another study showed that in post-menopausal breast cancer survivors, exercise lowered the risk of mortality and the stage of disease at the diagnosis did not matter. Yeah, another study found improvements in cardiopulmonary function and fatigue. And these survivors in this study were enrolled in an 18-week program that started only six weeks after their chemo. And these positive effects persisted at their one-year follow-up. So all these studies emphasize that modest lifestyle changes have been shown to result in clinically meaningful improvements to combat the decline in colorectal cancer survivors, especially older and overweight survivors. And then the next section of the article talked about how physical activity in colorectal cancer is preventative across the disease spectrum. So one of the studies I thought was interesting, it was a meta-analysis of 60 different studies and suggested a 20 to 25% reduction in colon cancer risk in people with the highest level of activity and the type of activity, the highest level of activity, and the type of activity did not matter. And then this same study also mentioned that public awareness of the role of physical activity in the prevention of colon cancer was low. And all these effects, interestingly, were not seen in the epidemiology of rectal cancer risk. It was more specific for colon cancer. So just kind of thought that was interesting. And then another study discussed, they used a different measurement, it's called MET hours. So MET stands for metabolic equivalent task, and it's just another way to measure physical activity. So you can see on the table, just a certain number of hours of this certain activity, so this activity was walking, translated into MET hours. And this study found that physical activity of at least 18 MET hours a week was associated with a lower rate of mortality. And the protective effects of exercise could be seen with as few as six MET hours per week and as many as 30. And so the upper limit of being 30 kind of potentially suggest a threshold of activity having any beneficial effects. And these studies just kind of emphasize that physical activity can provide additional benefit in the recurrence and survival outcomes above the benefit of just adjuvant chemotherapy. Okay, so now I'm gonna talk about some of just the biology behind how physical activity can lead to benefits in survivors and some mechanisms of action. So as you can see from this flow chart, these are just some of the hypothesized mechanisms. Physical activity can affect the insulin-like growth factor, aka IGF-3, aka IGF pathway, and AMP kinase signaling. So that's kind of on the right side of the diagram. And this leads to lower levels of cell proliferation and increased apoptosis. On the left-ish side of the image, it highlights how physical activity can block inflammatory pathways, which results in the downregulation of nuclear factor Kappa B, NFKB, AKT signaling. Ultimately, this leads to the decreased development of oxidative species and thus less DNA damage. So in other words, exercise can exert anti-inflammatory and anti-proliferative effects on the colonic mucosa by decreasing a lot of the tumorigenic factors. So the factors of COX-2, nitric oxide, synthase, and TNF-alpha are among those. And then some rodent models have demonstrated that running on the wheel or the treadmill inhibits colon tumor formation after exposure to carcinogens, as well as decreased polyp formation. And another study looked into how exercise can alter the insulin axis and associated high levels of IGF-1 with increased incidence of colorectal cancer. And it associated a high baseline IGF-binding protein 3 with a reduction in the mortality. And this I think was because IGF-binding protein 3 binds with IGF-1, therefore limiting the tumorigenic potential of IGF-1 and its bioavailability. Whoops, oh no, how do I go back? There we go, okay. So the next section kind of talks about some of the barriers that survivors face when trying to participate in physical activity. So a lot of survivors reported uncertainty about the type of activity that they should perform. A lot of them didn't ask providers for recommendations, and they also expressed that they would prefer not to spend additional time at the hospital to participate in any physical activity program. Additionally, they could experience a lot of effects of treatment, such as like chronic diarrhea, neuropathy, as mentioned before, difficulty sleeping, digestion issues. They can have a lack of time as well. And what I thought was really interesting was that providers can also provide conflicting messages about the ability to exercise in that colorectal cancer survivors were less likely than a non-cancer adult to be recommended exercise. And a lot of providers admitted to lack of knowledge about the benefits of physical activity in their cancer patients. They did not feel comfortable making recommendations, and they were not convinced that cancer survivors were capable of exercising during treatment or would even follow the recommendations. And then they also believed that lack of time during office visits to provide, there was a lack of time to provide this kind of counseling. And then in terms of like motivational theory and self-determination theory, these theories kind of state that survivors will engage in behavior if they believe that the benefits of the behavior outweigh the risks of not performing such behavior. They also, survivors are more likely to engage in a behavior if there is an authority figure that values and encourages the behavior. And if they believe that the behavior is under their control. And I think this is important for future physicians and current physicians, because the physician can play that role of the authority figure. And one of the studies, a breast cancer study found that the oncologist's recommendation resulted in a perceived approval and support and greater belief that exercise is important and led to greater motivation. So I think that just kind of goes to show that physician encouragement may be the greatest catalyst for change and for long-term adoption of certain behaviors. And so the article talked about some current intervention strategies to get survivors moving. There is a program called Live Well. It is a four-month personalized lifestyle intervention that focuses on tailored advice and supportive delivery of interventions, as well as the ability to have one-on-one feedback. And the participants in this program have felt that starting the activity like three to five months after completing their treatment allowed enough recovery time without losing motivation. Some other studies in other cancer populations suggested a patient preference for home-based interventions. Patients really preferred goal setting, print materials, as well as telephone counseling. They also wanted to know, patients wanted to know more information on the risks and the benefits of intervention, and also expressed interest in getting all this lifestyle information earlier in the course of diagnosis and treatment. And then some other current ongoing studies called IMPACT, which stands for I'm Physically Active After Cancer Treatment, and the CHALLENGE trial, which stands for Colon Health and Lifelong Exercise Change. I don't know who comes up with these acronyms, but they're always so clever. So these clinical, or these trials will, they are working to address the impact of structured exercise interventions on certain outcomes, such as cardiopulmonary fitness, specific biomarkers, and fatigue, and cost effectiveness. So the authors of this study were hopeful that these ongoing studies have the potential to eventually help guide clinicians in future recommendations for post-treatment exercise, and as well as provide a better understanding of a lot of the mechanisms behind their preventative effect. And so some future directions for research. The future research should focus a lot more on the biology and behind physical activity and the logistics of certain interventions. And I thought it would be interesting, the article didn't mention this, but this was kind of just, I thought it would be interesting to investigate if different types of activities led to different benefits, because a lot of the studies that said that the type of activity did not really matter, but I think it would be kind of interesting to compare like low intensity versus high intensity training or like strength training versus cardio. And a lot of, the authors also suggested a randomized clinical trial of interventions in uniform populations defined by stage of exercise, contemplation, and then using the endpoints of disease-free and overall survival to assess post-adjuvant treatment effects. So there's a lot of work to be done, I think, in this specific population. And so just to wrap it up and summarize, physical activity, as we all know, is an important factor in prevention of a lot of diseases in the general population, but it is now kind of emerging as an approach for lowering the risk of recurrence after colon cancer diagnosis, as well as improving prognosis. And the benefit in rectal cancer is a little less clear. And then I thought a very important take-home message was that providers should encourage colon and rectal cancer survivors to engage in routine activity as part of their rehabilitation. So that is all. Happy to take any questions if anybody would like to discuss anything. Thanks, Michelle. With regards to the conflicting messages from providers, do you think it's a lack of awareness or education, or is there some legitimacy to a difference of opinion? That's a good question. I feel like the time constraint that was mentioned in the article could play a factor in it, and perhaps physicians perceive their cancer patients to not be capable of physical exercise without actually having those discussions with them and seeing what, assessing their capabilities and just kind of making assumptions. And so I think it's important for physicians to not only work to educate themselves, but also work to educate their patients about the benefits of exercise during and after treatment. I see a question in the chat. Great presentation. Did any of the studies break down physical activity based on demographics such as age? And if they did, did the requirement for an efficacious amount of physical activity differ between age groups? I don't think that any of the studies used age group as a classification, which would be also another really interesting thing to look into. Christina asked, I believe you briefly addressed this, but how did they choose the 150 minute per week criteria for physical activity? I believe that was from the American College of Sports Medicine. I don't know exactly how they came up with those numbers, that specific organization, but I could definitely look into that if you wanna chat more about it. Yeah, absolutely. Well, great job, Michelle. That was awesome. Thank you. Does anyone else have any more questions for her? If anything else comes to the chat. Otherwise, great work from both of you today. Thank you both so much for coming in and all of you for watching. Again, we really appreciate having you. This was hosted by the Association of Academic Physiatry's Medical Student Council, and we try to have these at least once a month. So if you're interested in signing up at all, you can just Google the Medical Student Council Journal Club, and there's a form you can fill out online. And we'd love to have continued participation. So thank you everyone for being here. Awesome job, Wally and Michelle. And we'll see you guys later. Good job. Thank you guys. Thanks everyone. Bye everybody.

foot orthoses

clinical outcomes

lower limb injuries

biomechanics

prefabricated foot orthoses

customized foot orthoses

barriers to physical activity

survivors of colorectal cancer

intervention studies