Alright, so as you see on the today's slide, we have a lot going on, a lot of great topics, some great speakers coming from all over. And and I also wanted to make sure that, you know, I did make sure we have some breaks. I don't think that was reflected well in the the agenda when we first send it out. But there are 15 minute breaks, at least 15 minute breaks between speakers so that you can get a break from the screen. And like I said before, if, if you need a break and turn off your Zoom video, that's understandable. I know it's hard to be on the camera all the time. But it's also nice to see smiling faces and to have some sort of interaction. So interaction is not just virtual, but it's also verbal. And that's probably one of the things we really miss about these onsite meetings is having that verbal interaction with our colleagues and getting to meet new people, are seeing people we haven't seen in a long time. So we do have the chat feature and I do encourage you guys to use the chat feature to ask questions, share your thoughts or comments with the group. You can also reach out to people individually. So if you see somebody, you have seen a while and you want to say hello, by all means, use that chat feature. That's what it's. Therefore. We've learned a lot quite a bit this year hosting virtual meetings. One of the biggest advantages of offering our meeting virtually is that it makes it more accessible. You don't need a drive anywhere, you don't have to worry about parking. You can wear whatever you want. And on a nice day like today, you might even venture outdoors. So if you take your laptop outside to attend the talks later on, I totally understand that. Hopefully your connection with Wi-Fi will hold onto the connection when you do do that. But I do miss the in-person interactions and I hope that sometime soon that will return. Okay. So the agenda above shows that there will be breaks like I mention, and please use those brakes, get up and move. Just like we at Ano advocate as physical therapists, it's important not to sit at your desk all day, so incorporate your little stretch breaks when you can. Alright, so I wanted to start out with some positive things. So 20-20 had a lot of not so positive things happened. And but I think we've learned a lot. And I think it's nice to do a shout out for some nice things that did happen. So deep. I'm going to catch myself from time to time, say DPCA versus APHA Delaware. But APT had Delaware has done quite a bit this past year. When we had to go virtual, we made the transition pretty seamlessly. We held all four chapter meetings virtually. And I think it also. I was successful in the fact that we had more attendants than we typically do with in-person meetings. And that's mostly I would attribute to the fact that barriers were decreased. People could access it anywhere. So if they wanted to do it from home or if they were just finishing their day at work. It was an easy thing. Or even on the drive home, they could possibly even listen to it on your phone. We actually hosted for virtual town halls. I miss counted first virtual town hall was the coded our response to Coven town hall and getting information out to members as quickly as possible. So beyond the town hall, we also created more information on our website sweep quickly and with the assistance of our executive director dan Clem, provided a lot of resources to timely resources for members to get information about payment and business operations and how to be safe during this time. Another thing that we did do this year was we had webinars. We worked in collaboration with the New Jersey chapter and hosted more continue it continuing education offerings through these webinars. We also, through a PTAs encouragement, APT to believe in rebranding. They created a new logo they read. And they also invited all chapters and sections to adopt the logo or a form of it and and adopt a naming convention that identifies a PTA first. So that we recognize that we are part of a PTA, that we're not a separate institution, that we are part of the APT family. And so that is why our name has been changed to a PTA, Delaware. And I would say the majority if a great majority of the states, the chapters and sections have followed suit. So if you do good at APTs website, you go to a sections website. You will probably see that logo that was on the backdrop of my spring of a triangle. There was a lot of thought and philosophy going into the, the triangle because we've always had sort of a triangle in our logo. But it's also wanted to portray movement. And so that's why it has this kind of visual of like a 3D effect of movement. So so you will hear us from time to time still call ourselves DPCA, and that's perfectly fine. We still own that meme. And legally that is who we are. We're done, we're Physical Therapy Association. But for continuity and identity, we are. Going to continue to refer to ourselves as a PTA, Delaware. Another great feat we did this year that I'm very proud of is we selected a centennial scholar. So one of our members whose names? Josh Smith, Me, is a physical therapist at bay health Memorial in Melbourne. Applied for this program and we selected him to represent Delaware. Apk is offered this opportunity to also chapters and sections. Currently there are ADA centennial scholars. Their goal is to have a 100. And these centennial scholars will spend all of next year working on a capstone project for the chapter or section that they're representing. They will be meeting and meeting with leaders through out our association at the national level to talk about leadership skills and, and really develop them to be a future leader. So I'm really excited. Josh, I believe, has great potential. He's very excited, has lots of great ideas already. So you should be hearing more about Josh in the coming year cause we will keep you updated on the project that he decides on and how that goes. The other thing that we did this year was we created a telehealth committee. And this was a very timely response. We've been interested in telehealth for awhile. But with coded happening, that kind of facilitated moving forward with establishing a committee and identifying a committee chair. Lisa Barner is our Telehealth chair. And she's not able to join us today, but she's been very actively involved in attending meetings at through offer through a PTA, as well as keeping up on the literature. So she keeps us in tune to what's going on. And one more thing that hasn't happened yet but will be happening is we're gonna be offering CPR training in December. The details are still being too firm to but we're looking at December 12th and we will post that information on our website, as well as sending out e-mail information to all members. So CPR training is a requirement for your license and so licensure renal is due by the end of January. So if you need CPR training, this may be a great way to fulfill that. I think the fee for that training will be $60. So again, details will be coming. So keep an eye out on our website. Alright, so there is a message I want to share with you from George Edelman, georges, Our payment chair. And he's been very busy over many years. I mean, it's not new. I mean, he's always been very active communicating with payers and our state, advocating for change when change. Need, events always needed. But he's always excited to share news even if it's small baby steps of positive change like this one. But we want to make sure that you're aware. And so I will just read the message that he emailed me and pass that on to you. So he said, Dear members, Several years ago when Edna wrote out their new utilization management program, read MD, API team representatives from the mid-Atlantic states mobilized and we began meeting with them on a consistent basis to discuss the program and point out the multiple issues with the UN program. On our DPT website, you will find a recent announcement from now regarding an improvement to the utilization management program. We recognize it is a huge administrative burden on our practices. The new changes should make it slightly easier. And as always, we enjoy feedback from the membership. So this slide highlights the changes where the change being made and also references that more educational materials will be posted on our website early next week. So again, a shout out to George has been a strong voice for Delaware PTs and PTAs and yeah. For advocating for payment reform, reducing administrative burden that has been negatively impacting our profession. So thank you, George. Sometimes I'd have trouble advancing my slides up here without my right other good news to share. So it's official. I'm sure you've seen some of the messages we had out there about the proposed Wilson red change regarding telehealth or current? Well, you have a telehealth rules and regs regarding the impersonal requirement for initial evaluations, reevaluations, and discharges. So the board has met, they've listened to the public. They had a public hearing. Letters were received and they voted and effective November first. So now the rules now indicate that there is no in-person requirement for the Telehealth For any telehealth visits. What and this basically makes a lot of sense because it's it's just it's a it's a judgment call. It's not to say we have free range to use telehealth for any patient. It's it's it goes back to their rules and regs that precedes that in-person requirement that was listed there. It says the licensee shall be responsible for determining and documenting that telehealth is an appropriate level of care for the patient? If it's not appropriate to do telehealth for the initially Val worthy re-evaluation. That is your decision, that is your judgment as a physical therapist to make to say I need to see you in person. So that was part of the at the reason why we felt it wasn't necessary to habit impersonal requirement listed. And also that it was a barrier because there are things that if people need care and they can't come to your clinic in situations like Coven or distance or finances or whatever it may be. We wanted to minimize or eliminate that barrier for access. And and there are there are possibilities of times when you can do an IV our reef, our discharged with outs, lay your hands on the person. So someplace to report that. So if you go to the professional licensure boards website, I haven't seen this posted yet. I did reach out to the state board president Angela Hutchinson or I'm sorry, that's remain Angela Smith. To see if if communication will be coming from the board. I haven't heard anything back yet, so but I did but I do know it did pass. And so again, great news for us. Okay, so election results, so attorney annual meeting, this is also the time to elect new leaders for the coming years. These are typically two-year positions, but the first position of nominating committee member is a three-year position. This committee is consist of three people and you serve it for three years, but the last year being you serve in the role of chair of the committee. So I am pleased to announce bright people. He was a write-in for the position. He is a native USS Essex County. So it's nice to get some diversity from all counties being represented. Brian works at Edelman spine and orthopedic physical therapy and Dover. And we're happy to have some new faces and some new blood in our leadership group. Next, I'm really excited to also announce another new person joining our group. Suzanne why Eisenberg? Sue was a director of clinical operations for Biada home care. In addition to direct patient care and clinical operations management, Sue has a wealth of experience with Utilization Review, Policy and CMS regulatory requirements. And these are all, you know, these are wonderful skills and experience for a delegate to have and I'm sure she will represent us well, the House of Delegates. So sues actually attending this meeting. So feel free to say hi to her in the chat. And Dave will demand has been re-elected for a second term as Secretary. And as I mentioned earlier, we are very appreciative of David's continued service to our group. And last but not least, the President has been awarded to Steve Sally, so congratulation, Steve Steve has been an active member of our Association since 1987. So most recently he has served in that role vice president. And as I've said already, he's been a huge help for me, especially this past year. Steve is very responsive. He's a good listener and he's a people person. As CEO, performance, physical therapy and fitness since 1992, he encourages his staff to treat patients as if they were family. And that is something not only did I hear him say at meetings, but it's also, you know, except briefly worked with Steve for a period of time. But it's also I witnessed it bounced and Steve practices the I call it the golden rule with everyone inside the clinic as well as outside the clinic. And so Steve, again, congratulations, you're going to make a great president. And so before I move on to our keynote presentation and introducing our speaker, I'd like to open this time up for some questions. If any of you have questions regarding the information that I just presented or questions about anything else that I haven't talked about. This is the time or comments. So feel free to unmute yourself. You can raise your hand either through an idea or there's actually blue hand icon you can click. So I'll just give you guys a few moments to think if you have any questions. I think we have at least a minute or two before we have to move on to our keynote. And this would be a good opportunity to just let everybody know if you haven't been able to rename yourself on the zoom so we can get figured credit. Please send me a check and I'll go ahead and create a name for you that can be your first name, your last name, and I'll make sure that you get credit for being here. So thank you. Hi, Stacy. So we congratulate you. Thank you. Thank you. I'm hoping I can serve anybody well, looking forward to it, I was just wondering if anybody wanted to join the committees, how would they best do that if anybody on the Zoom wanted to do that? Thank you for the question. So that's, that's a great opportunity to shout out the opportunity for joining, can join a committee in a small way or big way. There's lots of things that APT Delaware could use assistance with. So if you're not sure what committee there on our website is a list of committees ranging from events. So like I mentioned earlier, Cameron is the events chair so you could reach out to camera directly and see what he might need help with. You might even have ideas that we haven't done or we used to do We haven't done in a while. And it might be an event like a fundraiser or or something in the community. We, we love to get some people with energy. Who want to either pair up with somebody to do something or envision something and maybe do it as a larger group project. So a committee is a great way to just kind of dip your toe in and try out to see what it's like to be involved with some really great people. So I'm trying to think. If you are interested in, you want to talk more about opportunities. You can reach out to me. You could reach out to our new President, Steve rough SLE. Or you can also reach out to our executive director, dan clan. I Carolyn, I can't hear you very well. I love your dog. Mainly because can you hear me now? Now I can hear yet because my microphone was in my ear. So congratulations to everybody. That's just great. Thanks to you for your leadership. And I want to know if Steve Rapa, Sally is going to expect this all to call him king. So everybody, thanks for a great midi. Annoy, you all have done this here. Thank you, Caroline. I want to answer that, but yes. I'm I'm I move that. We all try to impeach me. Oh, unimpeachable. I'll be 10A counters. I'll be your poll grow greeter. Madam. You bring a wealth of experience and that's to be recognized by you by, while I have this mike, I will say this. It is so easy right now to get involved and to add to this dissociation. And it is truly a function of the constituent parts of this association that makes it great. So there is never a better time than to join and to be part of this and to make this association mostly it could be because we're here for you. We're here to make your professional life. It can be in Delaware. So join it, join in EC that everybody friendly, everybody's open and everybody's welcoming. So thanks for just give me that. Met Madame President. Alright. Thank you, Steve. Alright, I have time for one more question or comment. All right. Hearing none. I think it's time to introduce our keynote speaker, so let me jump back to our screen. All right. I don't know why my buttons are showing on the screen, but there we go. All right. So if you Nia low started to break, you might want to get up for about ten seconds, move around a little bit. Once I get my slides ready, I will begin the introduction. Alright, gene, how am I doing? What's good? Okay. Oops, sorry. Ok. So I am very excited to introduce our keynote speaker today. Matt Highland is a physical therapist with over 28 years of experience as a clinician, private practice owner, educator, researcher, and advocate. For 23 of those years, Dr. highland was co-founder and bone or a dry physical therapy and rehab of private practice in Westchester County, New York. Matt currently is an associate professor at Mercy College and is committed to preparing the next generation of physical therapist. Has also had the opportunity to lecture all over the country speaking on the topics of leadership, health policy, and advocacy matters. The past president of the New York Physical Therapy Association. And during his tenure, the NY PTA received BAPTA outstanding component Award for 201220132014. He was elected to the APT board of directors and then 2018 was elected vice president of the PTA. So I'm excited to share that Matt plants to run the position of president of the PTA in 2021. So this was news I just found out yesterday, so I'm thrilled because I truly believe Matt's going to be a phenomenal President. So I'm excited for that. He's running. So before I let Matt takeover, I just want to share a few more things about Matt. So mad is also a big Red Sox fan, which I think is very cool being that he's from New York. For those of you who don't know, the Red Sox and Yankees rivalry is one of the oldest who's famous and fierce rivalries in American sports. And if you don't know what I'm talking about, just google the curse of the Piombino. So I love this tick. This is map, this white man at Fenway Park. And so I got to meet Matt through my attendance at Northeast caucus meetings over the years when I served as chief delegate. So this picture here is some of the Northeast caucus group when we met in Boston in 2013. So these meetings are where the president and chief delegates from the Northeastern states get together and discuss business, mostly related to preparing for the House of Delegates. And at the end of this day-long meeting, we would do something social like. Go to a baseball game. So I've had the opportunity to meet some great people through the Northeast caucus and Matt is certainly one of them. So I added this one additional screen. There's man, his wife, but I also recognize a lot of other friends and I don't know if anybody sees other Delaware Ian's in the crowd were former Delaware and the crown. If you want to throw it into the chat, go for it. But I'll just, I don't know if you can see me circling, but that's the other. It is. Thank you, Jeanne. So that's Irene Davis, formerly Irene Macleay. And that's her husband, Daryl Davis. They are Bostonian snail the Living Well, I think they just move to the Cape, but they were living in Boston and I reached out to them and then we add some extra tickets so we invited them along. But PTs are, we are social beings and, and I think that's what makes it really hard to have these meetings over the internet as we lose that social connection. So I really do look forward to the opportunity that we can see each other in person again and have fun. Alright, so, oops, sorry. I am going to unshare my screen. And I'm going to let Matt take it from here. And Matt, you are going to share your screen and open. Yes, that looks great, right? They thank you so much for that fantastic introduction. I I I'll, I'll have openly admit right up front, I have that exact same slide in this presentation, so that warms my heart. I've had the great opportunity to get to speak throughout the summer, in the spring to a number of groups. It's one of the things that this virtual world is opened up. And I spend most of the summer and spring bearing the mantra, vote and be counted and make sure that you vote in however your heart lead you and make sure you're counted in the census because that's important. But now that we're past the election, I've had that had to change my approach for today. So you're getting all new material. So hopefully this goes well. I'll also say that I love all of your virtual backgrounds. With your APK, Delaware. I've given up on virtual backgrounds. So you're seeing or newly painted wall here in Saratoga, New York. You've already met my wife in a couple of slide, those last couple of slides, but this is the two of us earlier this summer, we did a virtual 5K to do some fundraising and support like the All Children's Hospital, which is a way in a forum to advocate for people, which is part of today's talk mission, vision and advocacy. Stacy gave me the punchline already. I grew up in New England, so I am a Boston sports fan. The bottom left, there's my child at home and my high school stoning to nice cool. It looked nothing like that. I lifted that photo off of the internet. Much smaller when I went there. But special places in my life and part of the reason I'm a Red Sox fan. And Steve, you talked about being impeached and was elected president in April of 2010 here in New York. And then we went to the House of Delegates in, I'd say June of 2010, which was in Boston. And a dear friend of both Stacy analyzed. George COG shell was president of Massachusetts at the time and stood up on stage and said, I'll forward thinking New York was to hire a Red Sox fan as their president. And I think they were trying to figure out the impeachment process immediately at that point as well. So I feel I feel Yeah. So for the record, this is not me. But in fourth grade I had the chicken pox. And I'm sure all of you who've had the chickenpox probably at some point in your life and had our different experiences with it. For me, it was very severe. I had it all over my body. I had it in my throat, had an internally and it was something that both physically and emotionally scarred me. And I miss some school and I don't remember how many days that that's faded over the years, but I I do remember that experience in fourth grade and then on the first day of school next year, something significant happened in my life and not as well covered by the media, but for me it was kinda Lou Gehrig, Yes, sure. Maybe cow in ask. But from the first day of school in fifth grade through my high school graduation, I had perfect attendance. And to this day, it's something that I'm very proud of. L, So I have to admit that sitting here in front of the computer doesn't play to my strengths because I'm a Romer in a mover. So it being anchored down as a bit of a struggle for me. So I try to stay still here and facing my microphone so i don't freeze and be told I'm unstable by my internet, which is how I felt sometimes since March of this year. But I stoning, It wasn't the best student for sure. Obviously, attendance wasn't a contributing factor to that. Then I'm easy for me. I also played three sports and started in all three of them. And while I was a good athlete, similar to my stature as a student, it didn't come easy for me and I wasn't the best. These are just a few dear friends of mine who are tireless advocates here in New York State. Isn't my dad. He passed away March 22nd of this year from a brain tumor which least diagnosed on December 26th of last year. This photo was taken in 1975. That was 29 years old. I was five. The interlope or on his right as my sister Rebecca, who arrived in Rwanda, perfectly wonderful experiences, an only child. My dad was a tireless advocate in his life. He was an educator, a leader, just an all around wonderful man. He started three not-for-profits. We CEO of all of them. They all continue to this day. The first was called Martin House, name for Martin Luther King, which was a home for that welcome to individuals with mental health disorders and we're bordering on homelessness. At Martin House, you found a community of people going through similar struggles. Nurses who are willing to help make sure you state on your medications properly if needed. And you were trained to help you reintegrate into the workforce. The second was themes river family program, which welcomed women with children who were leaving environments of domestic violence like Martin House, one of the key elements was community safety and obtaining work skills to help you be self-sufficient and supporting you and your family? My father was a huge supporter and advocate of mine. And well, I didn't have the best grades and wasn't the best athlete. I was persistent. And I realized at a young age that success for me it wasn't going to be because I wasn't because I was just present and attentive, but I had to be dedicated and tenacious and have to work outward to the next person. Those are values that were instilled upon me by my dad. I was accepted into PT school, did the college the place that still near and dear to me. My son our son ended up going to college there as well, which was a very special experience for us. But I, while I was accepted at Ithaca, I was turned down by some other programs and I had a few options. But the day that we went to Ithaca and I saw the campus, it spoke to me and I knew that was a place that I was gonna call home. And the photo on the left, the right tower. My freshman year I lived on the 13th floor overlooking that gorgeous Cayuga Lake. So by Father paid tour wonderfully for that view, but I enjoyed every minute of it. And, you know, the rest of the story, right? I had perfect attendance all four years of college. I never missed a single class. My physical therapy degree, my entry-level degree is my bachelor's. And again, it wasn't an easy journey for me my freshman year, I actually ended up on probation. Anatomy, chemistry, biology were difficult, but I worked hard and I got I got through it and persisted and was able to get off of probation. Second semester, my junior year, I continued to struggle, not because befor for sure, but I struggled emotionally. Wonderful relationship that I had been in ended by her, not me. I my 21st birthday nonetheless, as missing home, my beloved patriots were horrible, which was a real thing in the eighties and nineties. And things started to get away from me. Of course, I worked hard, but it wasn't helping. I remember going into my histology pathology final exam knowing that I needed at least an 85 for me to stay in the program. And I came out knowing that that probably didn't occur. At that point, I was thinking, how am I going to tell my parents? I felt ashamed. I felt like I failed. I wanted to crawl into a hole. And I had kinda meet this plan that I was just going to skip the rest of my finals and figure out what it is I was gonna do with my life. And the next morning, I got a banging on my door. I was living with two classmates, two good friends of mine who were in house off campus, and one of my housemates, Scott satin. And now Scott and I were very close and college and we've kind of lost track of each other after college. But he's somebody who's played a major role in my life and to this day is out there and probably doesn't know how much. But he's banging on my Dory, opens the door, I'm still in bed and he says, let's go, we gotta go. It's our massage final. So yes, I actually had a three credit course in massage when I was in PT school, not soft tissue mobilization, myofascial release or anything else? It was massage. It was the early nineties, so I don't know what you want, but I also mastered ultrasound and can apply hot and cold packs with the best of them, but Scott would have no part of it. You open the door. He came in, actually physically grabbed me and brought me out of bed and went to my final in my sweatpants and sweatshirt. And and I took my exam and passed and definitely a form of advocating for somebody. And since I don't have a photo with Scott, no internet at the time, no cell phones. I thought I'd show you my sister, a grown up at a wedding, and my mother as well. Since that's gotten a lot of airtime so far. We're very important to me. So you do know the punchline of the story, right? I'm a licensed physical therapist. I'm here with you today. Decades later when serving as New York physical therapy President, I asked or then treasure steve LAR, Dr. Steve LAR, who was the professor that histology pathology class in Ithaca. And I told him the story and what I went through and I asked them how how it is I ever passed and he just smiled and he said to me, you know, I really don't remember any of that. I just know that we believe that advocacy. It took me a long time to find this photo. And I so appreciated Stacy's and they make me smile. But that's the BLE our way over to the right, the farthest right of the screen, gentlemen over there. And in fact, there are a number of dear friends and mentors in this photo that had been incredible advocates of mine over the years. We've encouraged to run encouraged me to run for chapter president. It was Gabe yank. What's right in the center there next to the New York sign, next to Dr. Marilyn Moffitt. And Gabe was the one who encouraged me to run for chapter president and was tireless around me running for the board as well. As you're all here today doing the same thing with each other. So you've met the superstar in the slide in the top left and December second, 2017, she was diagnosed with HER two positive breast cancer. It was given a 50% chance of a 3-year survival rate at the time. And today sheets cancer-free and kick some serious but and that was photo taken at my sister's wedding in 2018. And sometimes you just need to advocate for yourself and your family. So here's a little story. You don't get to be in my slides unless you, you're positively impacted my life and you're somebody that I care about. And every slide with the photo means something to me and has its own story to tell. And on the right are my good friends kept chicken anthony D. Flip. I had the opportunity to serve on the board with for a number of years and this was us together in Lake Tahoe. And those are my superhero red shoes that, that become very important in my life for a lot of reasons. So here's the punchline and we talked about George and earlier Stacy was talking about George. So you can see if you could seek him out in this photo. And obviously Stacy scenario here as well. And, and sort of the story is advocacies Hart, who it takes time to find out who to advocate to, how to reach him, how to write them, actually go see them. And it really fits into the bucket of healthy no. Meaning doesn't APT eight Delaware or the American Physical Therapy Association? No, this is an issue. You know, why aren't they going to do anything? Are they in touch? In the world of advocacy, often with payment, effort is judged by outcome, just by those who are not necessarily involved in the process but were impacted by the outcome. I was asked to run for the API tape where the number of times, and honestly, I never envisioned being the chapter president. So the idea of being on the API tape board was just such a foreign concept to me and something that hopefully didn't really interest me at the time. But then in 2013, this happened, transforming society by optimizing movement to improve the human experience. And eight, so vividly remember sitting in that House of Delegates thinking to myself, That's where we're going to go as a profession. I'm all in. That's the team I want to be a part of and I is the gavel dropped them that house I found a member of the nominating committee and I said, I'm interested if if you're willing to consider lading me. So here we go. This is at this point you're like, why is he telling us all these stories about going back to fourth grade and then the reality as it is because Stacey said you get 30 minutes and I didn't have that much material after I lost my vote would be counted. But, but I'm gonna give you some hard query PTA stuff, some insider knowledge for you. You are the very first people to see this other than my public policy and advocacy committee colleagues role I get to chair as Vice President dissociation. So these are every two years insistent with the legislative cycle BAPTA drafts and then passes an APK public policy priority agenda. And it's the things that we're going to actively advocate for in Congress and the White House. It's very external facing document and one that is real driver of our budget and our actions. And we've been working for about a year or public policy and advocacy committee and preparing this document, which I'm going to be delivering to the Board of Directors next week at our meeting, so you're seeing it before them. So knowing this is being recorded, just let President done. No, please. I will also preface this by saying that since it hasn't been asked by the board if they had not a 100% end up this way. But as I said, it's an external facing document. A lot of discussion of our group went around the quadruple aim of patient satisfaction, better outcomes, lower costs and provider satisfaction. In some of the initiatives will have to be the drivers and some will be collaborators. And we have four main pillars that we've identified. And underneath those we have some objectives. A group, when we started, identified some guiding principles before we had any conversations. One was to be bold to live in the here and now we understand obviously the 9% cut, which affects me, will affect all of us through, we have legislation in Congress right now during the lame duck session to hopefully have that repealed for the next two years. Telehealth, which I'm sure you talked about before I hopped on the phone. And then the coding initiative because well, they're in the here and now, and of course we're going to deal with those whether they're in our legislative agenda or not. Be very positive and our messaging, we want members of Congress and the White House to, to read our document, understand what it means and can be positive. We want it to be clear, be very patient centric and aligning with our vision. We see it as an opportunity and pushing us as a community in addressing racial disparities. And obviously, how this election turns out will matter a great deal. As to what happens in not just the presidency, but what happens in controlling the Congress in the House as well will dramatically impact what happens moving forward with further stimulus packages or with our ability to move a lot of our agenda. So there we go. So our first pillar is population health and social determinants of health. Population health and social determinants of health. Bapta urges Congress and the administration to enact policies that empower all people regardless of where they are born, live, learn, work, play, worship, and age to live healthy and independent lives. To dissent. Apk will advocate with federal policymakers and collaborate with stakeholders too. Support funding for prevention and wellness services, increased funding for individuals with disabilities education act, preserve and protect services provided and under Medicaid and Medicare. Advanced policies to increase knowledge about physical therapist services for individuals of all ages who live in pain, support programs and increased physical activity and exercise amongst all individuals. Advanced policies that ensure access to rehabilitation services, including physical therapy for individuals who are recovering from Coven 19, and advanced policies that support diversity and inclusion and the physical therapy workforce, including passage of the allied health workforce diversity act. Our second pillar that we're going to be presenting to the board is patient access and care that BAPTA urges Congress and the American administration to improve patient outcomes by eliminating barriers to health care services. To descend, APK will advocate with federal policymakers and collaborate and holders to guarantee access to a comprehensive health benefit package for all Americans with no arbitrary limits placed on people with preexisting conditions. Expand the definition of primary care services. Primary care service providers to include physical therapists, expand opportunities and public programs for direct access to physical therapy services. Increased the health provider workforce in rural and medically underserved areas by adding physical therapist at the federal student loan repayment program. Advanced policies to increase transparency to patients regarding cost of health care services and financial interests and delivery of healthcare services. Advanced payment coverage in broadband and technology infrastructure policies that will increase patient access to rehabilitation services delivered via a digital health and telehealth. Reduce patient out-of-pocket costs for non-pharmacological pain prevention, treatment and management services, including physical therapy, advanced policies to ameliorate the pavement differential for physical therapist assistance to ensure access to essential services and to enact legislation to allow physical therapist to opt-out at Medicare and privately contract with Medicare beneficiaries were actually trying to figure out better words for opt out, even though that's well-known in Our healthcare cycles and is actually in language in CMS manual. We don't think that that's overly well-known in Congress. So we're actually, Katie, nice and myself are trying to figure out a better word. There are third pillars, value-based care and practice, that BAPTA urges Congress and the administration to improve patient outcomes by supporting efforts to increase efficiencies and the delivery of health services that reduce administrative burdens to providers and ensure transparency to patients. To descend, APK will advocate with federal policymakers and collaborate with stakeholders to facilitate and support the development of demonstration projects to validate an alternative payment models and public and private insurance that increase administrative efficiency, promote effective patient outcomes, and expand interprofessional collaboration among health care providers, including physical therapists, advance policies that reduce administrative burden across all public and commercial insurance, and advanced financial and operational, operational incentives for the physical therapist profession regarding the Use, Certification and interoperability of electronic health records and other health information technology. And then are finer final pillar with outcomes underneath it are research and clinical innovation that a PTA urges Congress and the administration to prioritize research and clinical innovation to increase access to appropriate value-based healthcare services. To this end, a PTA will advocate with federal policymakers and collaborate and stakeholders to increase funding for rehabilitation research across federal agencies. Secure partnerships with public and commercial insurance to drive the delivery of high-quality, cost-effective rehabilitation services as measured by the physical therapy outcomes registry. And increased funding for health services research that includes physical therapist services as part of the solutions to advanced desired outcomes in population health. So sometimes looks like best and I'm a big golf or I actually play golf and high school and in college. And sometimes it's, it's quite easy as advocacy can be sometimes. And this is my dear friend, Jeff's vital, We're a PT classmates together and remained that remain the best of friends today. This was actually earlier this summer. And as I get near the end here, I want to discuss advocacy from a not so obvious perspective or maybe just an alternative one. And to do that, you might duck into the weeds for a moment. I'm just going to let you enjoy this slide for a second before I change it. And to give you a little perspective, I am still on the golf course, arguably golfing. So I don't know who these women are. The one on the right, most people would be able to pick out, that's Rosa Parks. And to her right, the left on the slide is Septima Clark and Rosa Parks advocated for quality on December first, 1955. Only 65 years ago. Most people don't know who Septima Clark is and they should. She was a teacher in the South, was fire due to our affiliation with the NAACP. He became the Director of warships at the Highlander School in tendency and integrated training center where people learned about civil rights. In one of her students was Rosa Parks. Ms. Clark was an advocate. Most people know about Rosa Parks and Martin Luther King actually invited Ms. Clark to be with them when he received his Nobel Peace Prize. But the other really important advocates and leaders are often never known. Most people don't go out and advocate to become famous or for the glory. But rather because they're passionate about an issue and they want to be part of making change. You're all advocates in some way, whether it's for your patients and getting them visits approved or appealing and insurance decision or get students are advocating for your students and classmates and faculty had to have high-level experiential learning opportunities are more overtly like when you send letters to your member of Congress or members of Congress encouraging them to support legislation to suspend budget neutrality, which would eliminate the 9% cut that's facing our profession next year. And things don't change because of luck. They change because people care and are persistent and tenacious and often in the face of great odds. And these are just a few faces of tenacity from last year's PT Day of Service. So a little bit of a fun-filled fact, I opened my first practice with my partner Frank fund only in 1995 and in 1996, a workers compensation rates here in New York State increased. And I said to my partner Frank, This is great, less than a year into practice and we gotta race. And it was the last one that we saw is physical therapists and stayed in New York until last year, which happened because of the tireless work of a couple of dozen people who kept advocating for patient access, an improved quality. Yet everybody in the state, whether members are not of our association benefited. And two years ago, after almost 25 years, the arbitrary physical therapy cap was repealed. Advocacy. And I could give it does another examples for sure, but here's the secret sauce. Be passionate and anxious, maybe above all, the great. So I started with a story and I'm going to end quickly with one. Well, Kip and Anthony are very special to me as R everybody on the slides and Lake Tahoe is amazing. The Superman shoes are a thing for me. So if you've looked through the slides, you can see another journey that I've been on my life and that's to become healthier and I've lost 90 pounds over the last year and a half, and I'm very proud of that. And the Superman shoes were the driving force to me. I put those on and they, they made me want to feel like I could be great. So feeling good. I got up early one morning on September 272019545 in the morning, I threw my red sneakers on and I went out for a walk. And this is the Pepsico Dam, which is not far from our house. It's the 1910 to 1918. And it you would never see anything that gorgeous, beautiful built today, most likely. But it is the last dam that creates the reservoir that will then become New York City's water supply. So it's pumped underground from where I live in Westchester County down to New York City. Now I'll pause for a minute and chair, a source of pride. When I started my journey early last year, I can only get up a third of the way up those steps. So you could actually walk if you were looking at the left side of the dam From the bottom of the damped to the top of the dam and its 249 steps. And on this day in September of last year, I'm bounding up the steps. I felt great. And I got up near the top and I clipped the 250th step. My cell phone went flying, my headphones came out. I landed on my knees. I was bleeding. I dislocated the DIP AND my left index finger. I gathered myself and just started to laugh and as being a PT way to put my finger back in place and dusted myself off and I stood up. This is my good friend and board colleague, Dan mills, and this is the two of us last year in Chicago at the House of Delegates. One thing about a pandemic is it really hurt your slide index photos of you and friends, but, and I think this thing was called The Egg. But Dan's an iron mantra, triathlete and an avid outdoors enthusiast and he has been a huge supporter of mine. I get these random texts, you know, would you do today outside? And he he continues to support and advocate for me and he says all the time that you just gotta put yourself out there, willing to go a little further than everybody else. And you're going to see great things in this world. Who after I took my tumble and how he got knocked down, I, I split up and dusted myself off just in time to see the sun coming over the reservoir. So thank you all for participating today and your passion that you're bringing for your chapter and for our association, and your understanding that we're better together and trying to make a difference together is very important. So why am I here today? Well, I'm your liaison, so I would have been in Delaware anyway with you. And and that's an easy answer. But the real answer is when a friend reaches out and says, hey, would you be available to participate in our chapters conference? I couldn't say yes, fast enough. So thank you for having me and I hope you have a wonderful day at your conference. And if there's time, I'd be more than happy to take a couple of questions. I always forget that. Thank you map that was wonderful, very inspirational. Thank you for sharing your stories. And what an interesting journey. And I think, you know, providing that insight of where we come from and the challenges me encounter. And it's a wonderful, it's a wonderful store it so thank you and thank you for sharing all those fabulous pictures and it definitely brought back some wonderful memories for myself. You know, I think that the catchphrases of 2020 we are going to be, you're muted. You're still muted. Can you hear me? Okay. Thank you. Thank you. Have a great rest of your day. Be two. By pi. Okay. So we are at Time for a little break, so go get outside if you can. It's a beautiful day. Will rejoin at 1015 with our presentation. And I don't have the name in front of me, but you've got a gene. Now. Fred Brady MC. Ok. Fred will be talking to us about Oh, my goodness, blood flow restriction training. Thank you. So we'll see you soon already. Infrared, Do you need anything from us or you could DO. I think I think I should be good to go. If for some reason my mike decides to cut out. Like if I start if I keep a certain elevated voice level might might should be just fine. But if I cut out for like five seconds, just let me know. And we can go. And now I'll I'll probably pop up. And I pop up the presentation here. Yes. Go ahead with Angular sharing and then I'll let you cereals. Sure. And I think the only question I have then is this, can you guys see my presenters slides or am I OK? Now you're dead. Okay, great, perfect. Already here will fear about five minutes editing at the University of blood flow restriction parameters. And if anyone has any questions throughout the presentation, just please ask and Gene and I will address them as they come up. More as yours. Looks good. Just reconfirming again, you can't see my presenters slides. We'll oh good. That's good. Great. Alright yet so I'm, I'm Fred. Work at University of Delaware. And when I first started learning about about blood flow restriction tree news actually through Johnny Owens course that they came to the university. So I understand that he's falling may I believe said nice part is whatever holes might I might have my presentation. I'm sure he'll fill nicely. But my job is to try to best take that course and apply it to our clinic. And we've only really had it for about a year. And I say about a year just with coding it. There wasn't we had a whole gapped, not really to try to apply things. So we we developed a general guideline, blood pressure letters to, excuse me, approval letters to physicians to try to best get this thing started our clinic on how we typically operate. I'm gonna talk a little bit about how we've tried to simplify things and apply it judiciously to our torque curriculum in our, in our clinic. So the objectives today are going to be to understand which population in presentations are appropriate for B if our application to understand program development of b if r in the clinical setting in a understands and physio, physiological, medical considerations before implement. Before I even get into this, there's a few assumptions I just wanted to put out there that weren't when I'm talking about things is and I'm talking about blood flow restriction. Trainee is going to be using an auto regulating tourniquet system. So not one of the manual blood pressure or excuse me, because that's how we were taught. It seems to be the safer option in terms of consistent occlusion pressure. So I just wanted to put that out. That's how I'll be referring to things that we've generally receive physician approval for post-op patients and patients with co-morbidities are co-morbid precautions that we need to be aware of and we'll discuss what that is the very end. Obviously, no one That's contra indicated for application. I provided a slide that I'll just glaze over, but you'll have for your reference to walking out of today. And that the primary goal of applications for muscular strength gains will talk about some other aspects for why we might use it. But that's the primary assumption of the lecture. And also that within our clinic, we're trying to teach students about evidence-based application. So a lot of the things I'll be talking about and why we simplify is to try to get them to think critically, objectively about why they're applying things rather than just trying to apply something. So before I even get into it, I was going to glance over a few cases that came through our clinic. Just so as I talk about things, you can maybe think about how you would apply it either based off your experience with blood flow restriction or based off what I'm lecturing on today. And then we'll rehash some of these cases of what actually happened. And if there's any thoughts like I didn't like that, I like that. I'm always open to hearing the thoughts. So first case was a 54 year old female who had a MiSeq to me. She had weight-bearing axis aligned that changes after them instead to me because they pulled out so much the meniscus that changed her weight bearing access. Over time, she started having more severe arthritic changes and was having had pain with simple things in life like walking stairs, chairs, in standing, get eight weeks if p t, But there was no changes in function or symptoms. The only thing that seemed to help her was unloaded brace that seem to correlate with what compartment was was getting more and more load because they're a weight-bearing alignment issues. And we had restrictions from the physician office, no equipment or no heavy loading in order to rehab her. And she has significant strength gain. So obviously I highlighted that because that's the main thought I want you thinking about how would you, how could be if RB helpful for this person or how could you tie that into your rehab? Case two is a 72 year old male with me pain after being pulled by a dog. Severe arthritic changes recommended for total knee. Seven now ten pain with again, the simple things in life and and he had to use a cane to walk with even less than 710 pain. He personally though, has not accepted a total knee as his as his primary option. So became and he's like, I want to try anything. I don't want to do the surgery and he's a fair age to get it, but he wasn't there yet. And the one thing that I was, he had no strength deficits per biotechs isometric testing. So then how would you apply this person or excuse me, how would you apply blood flow restriction in this case? The third case is, is probably the more exciting wanted to talk about sometimes that people think of blood flow restriction and athletes. But 32-year old female with ACL reconstruction, allograft with Cattell ephemeral pain, 8-10 pain with strengthening for Canvas stairs and walk. Api has been ineffective concurrent tens or noxious stimulation in allowing us to strengthen in open or closed chain. And she's about six weeks post-op at this point. So those are the cases just to keep in mind as we walk through things and outwards going to jump into the meat potatoes here. And so I'm going to move my boy, you guys, so I can assume. So. What is blood flow restriction training for? As I said, primarily, strengthened hypertrophy and we'll discuss distal proximal and some systemic changes briefly. We'll also discuss very briefly how it can mitigate atrophy and how that could be a justification for applying. It will also discuss how it can help people in pain and to encourage exercise or general movement. So like I said, we're primarily talking about strengthen hypertrophy in this lecture and how are clinically applying this and just trying to simplify it. But what we know is in terms of hypertrophy AT blood flow restriction training will outperform. It's matched 31% rep max group by what? By what I mean about that is a group that is performing at 30% of their one rep max without blood flow restriction tree. We will perform. We're not have as good of outcomes in terms by hypertrophy compared to blood flow restriction training if they're train at the same 31% rep max. But blood flow restriction training, we'll actually has similar results in hypertrophy gains as high intensity training. So high intensity training was defined as 80% of a one rep max, which is roughly around this eight repetition plus range given the chart you're looking at. So it actually shows that hypertrophy will be equivocal result as that group, which is great because we'll talk about what population that can be helpful for. In the main thought is here is that can get you in the door if your goal is strengthened hypertrophy, we know hypertrophy is a component of maximal strength, can be increased cross-section area and muscle hypertrophy, we get stronger. However. In terms of maximal strength, things are a bit different. We, as expected, it will outperform low load resistance training again adds matched 31% red cohort, but it does not outperform high intensity training. So again, that 81% rep max group, so it can get you in the door, but it may not get you to the finish line. And it make it to the finish line, but it may not always get you there. And we'll talk about why we're thinking of it this way. Because we are trying to get off blood flow restriction train if we can, knowing just some of these facts. And the big thing here is some of that there is a lot of evidence coming out about this stuff. It's pretty darn good. There's some devil in the details and it's this. What do they define as 80 as a high-intensity group? And I'll talk about how that's been variable in some recent articles to o. In terms of strength and hypertrophy, it initially was thought to only have distilled benefits. But that's not actually true. There are proximal strength gains that have been seen. So if you apply to the femur and you're trying to rehab someone with hip glute strength deficits, that is a fair application. Same thing for the arms. If you apply to the humorous. You could have strength gains in the shoulders, Chester scapula, back muscles. And there's even some systemic changes, not the strongest evidence, but there are systemic changes that occur. And by that what I mean is there was a study that had two groups. One group or both groups are performing squats, dead lifts and bench press at the scene. Repetition max, but one group had bloodflow costs on their their legs. The other group did not. Both groups got stronger, but the group that had the blood flow restriction cuffs on got even stronger on their bench press. But the costs were applied to the legs. So what they're assuming with that is there is some sort of physiological mechanism that this application is kickstarting. And I'm not going against that. Johnny may get into that more, but there are metabolic pathways, different theories as to why this is happening. But it's just something to keep in mind that you can get these systemic changes in people's strength gains. It can also be something to keep in mind if you're trying to improve lens symmetry index that the other side may get stronger along with the application of this to the invol Berlin. So no who is a truly four if we had to simplify it down to earth group is people with strength impairments that can't handle load. And that's the big caveat there is. They can't handle load because of pain. So not that they're weak, they're actually pain limited and strengthening would be the group too early to apply this to you right out the gate. I think there's a caveat here. That caveat is some patient groups including geriatric populations or people with not much exercise experience, maybe unfamiliar retraining a true eight to 12 ret maximal weight. And you may have to meet your patient where you're at. And that might be with lighter weights, but you need to be checking to see if that lighter weight is getting stronger and if it's not, then maybe blood flow restriction is the best place to start. I would argue that with the oughta regulating tourniquet systems and the prices for it, it may not be worth that if you're going to that caveat. But I think you could justify doing it in that group and that would be a group that's not limited by pain, potentially patient preference to because we do have to consider that and some of our evidence-based applications. The second group is people have post-op restrictions or exercise restrictions or had been immobilized or will be immobilized for long times. Your procedures? No closed chain, no active loading, things of that nature, and it will mitigate atrophy. So you may not be making gains, but you're not getting losses. And there is evidence that cute application of blood flow restriction coughs after surgery mitigates quad atrophy. Let alone if you can convince the physician that just doing some active range with the cough like long our quads or quad sets or multi angle isometrics if it's not going to affect the graph site, is that one way to potentially get small gains over time. The third group here is functional limitations due to pain. And this one I have to, if I explain is poorly, please let me know. But there's some systematic reviews and meta-analyses that show that application of blood flow restriction coughs in the form of a strength program will improve things such as 30-second sit, stand, six minute walk test, stair climb testing. So we know that's generally improving not only physical impairments as I discussed, but actual functional testing network they use to justify progress or discharge. So with that, really tell you how you're going to rehab them. So one of the things we've been doing anecdotally with some of our patients is not having strength gains, but they're having significant pain, excuse me, if they're not having strength limitations with isometric testing, but they're still having significant pain with stairs or walking. We've been regressing those functional tasks to the point where they can perform it with an acceptable pain level that we're choosing. For that case, applying the cuffs and exercise nomadic perceive higher intensity that none that exercise normally would be so like a foreign step up doesn't cause them pain, but age step up is unacceptable. That's why they're here in the first place. And we've been seeing that over time these patients can move on to six inch steps and move on to aid in steps and start walking uphill. And we think that actually is largely due to this last point of the flow. Restriction cuffs have an acute change in perceived pain in scenes of interesting things in a clinic of, and this is actually taught to us too in the continuing ed course. In the same findings that there's been patients that have had proximal distal realignments with shin picking, walking around, we apply to cough, the pain reduces significantly or goes away. People with fat Patty irritation neck and fully extend their knee for some reason with application of the cuff. People have to tell a femoral paying that don't have stairs acutely for an hour afterwards with application. So I don't know if that's why this functional training with the use of it has been helpful. But those are some people that were considering apply it to as well. But in the order of these points, its hierarchical. So first and foremost again, strengthen pyramids when you can't load them because pain is the number one reason we're applying this and teach our students to think that way. If anyone has significant post-op restrictions, that's next. And then after that, it's more anecdotal experience. Bring me the data that backs up your point. Have you tried other things? Are we stuck? Can we apply this now? So who is it not for? It's not for patients with specific co-morbidities and contra-indications. I'm not gonna go specifically through that. I do have a slide for you again, the backend, which is right out of our continuing ed course that we've been just using that we don't have anything else to go off at this point. And the literature on that is, is developing, which is nice, but it's pretty specific or some things that we would obviously not apply for that and we're not applying to people who can't be who can be strengthened, who were not in pain. So I talked about that caveat, but if they're not in pain, we want to load them. So that means geriatrics just because they're older. If they can be loaded, load them athletes just because it's new and interesting, if they can be loaded, load them. I understand there's caveats and I get that. I was an athlete in college to have a couple of buddies that play professional baseball. And I told them I was lecturing about this like, Oh, we do it all the time and I get why they do it. They do it for different reasons. So maybe at the other assumption I should have talked about is this is in the rehab setting. This is not in the sports performance setting. Or trying to play a 162 games of Major League Baseball and they don't want to heavily strength train. And the big reason again that I bring that point up is it does not outperform heavy load strength training. So if your end goal is maximal strength, we need to be training that muscle in that fashion. They use it in terms of dosage and parameters. The typical schemes and the evidence right now is 75 total reps. Always to complete all 75 reps. And the scheme is usually broken down into four sets, 30151515. It's already pre-built into RB If our units in our clinic, because the auto, auto regulating tourniquet system by Delphi is, it's just pre-programmed, easy for us, but wanted to provide that in case that wasn't known by. Or some people have units that's not the case. The exercise volume. Typically one to two isolated muscle groups or one to two compound exercises. And again, I want to re-emphasize that those are muscle groups or joints that if you're moving them, they are limited because of symptoms. And I'll bring that back it up as, as I go through case examples, we're not doing it for plyometric exercised as a whole. So examples of what the exercises would be like. Long arcs are straight leg raise, any knee flexion or bicep curls and compound program would be splits cloths, your typical closed chain stuff where strict, multiple muscles, maybe not an isolated When we look at this, we're we're really only doing three to four muscle, excuse me, exercises in the entire program. And we'll talk about why and how we wean from that in the future. So other joseph parameters to consider are keep an eye on the pace whose second concentric x_2 second E centric pates that it's an occlusion pressure. So starting at 80% for the lower extremity, 50% for the upper. And knowing that there are minimal values, that the evidence suggests we should stay within. The big reason I bring some of this stuff up is choosing our dosage of where to start isn't a perfect science. So we need to be as objective as possible of how the patient's moving, what the occlusion pressures act. So you're not adjusting things on the fly, figuring out why they're not getting stronger and why your weights are fluctuating. Because if anyone has an apply this, it's very intense. And there's some days where people just don't have it and you can't complete all your reps and interesting to look back in your program, make sure your objective really sure that it was dosed, right? So that's why there's all these parameters that we provide and to make sure we're consistent every day with doing it. The last bit is that rest times or our 30-second time intervals, those are pre-built into our program as well. So that's what we've been sticking with. The percent of one rep max is 15 to 30% of a one rep max. And I think the general thought or question, you should have it. Well, how the heck are you figuring that out if we're doing this with patients that are limited by pain, because the likelihood is you're not doing a one rep max on them or you're not getting a very accurate one. And that was kind of dilemma we had to start was where do we start from here and there. Johnny's continuing ed course, they provided an option of using an RPE scale. It'll just go to Omni RPE where you ask the patient what is 0 to ten? If you move this weight, what is considered ten in what is considered 0 and your eyes and picking something in the two to three range that they felt was wasn't 2.2.3 intensity and that's roughly around that 20 to 30%. What we ended up deciding on as a clinic was at the one rep will be calculated based off the maximal weight the patient keep eating their acceptable pain range for that condition are present on the knee extension machine. They tell ephemeral pain. We're saying that we're going to allow a three out of ten pain. I pounds, ten pounds, 15, they get to 20 pounds. They're having four or five out of ten pain. We're considering whatever number before that or working at to a closer number. 81 to to count increments to be their max and will dos that to start. And we'll let all these objective measures that I talked about determined that that was accurate. So if they're not completing 75 reps and we chose that weight that was 20 to 30%. We already know we overdose them. If they're doing it fine, then we progressed and from that point and keep trying to challenge them to the point that they're potentially almost not completing the raft, but they are still successfully completing the reps. And we're progressing forward. If I could ask a question about that, please. Are you calculating one rep max before the board for restrictions are put on or calculating. Okay, cool. Yeah, yeah, we are thinking about using our Biot axes are hand-held devices to come up with numbers. To me realize that's it's not clinically feasible in terms of the time it would take one for Newton meters that pounds. We could do a spreadsheet by just what, and we didn't think it was, it's not as perfect science. I said that's why we're just we're re-evaluating on the fly pretty much every day, reevaluating that they're appropriately dust. So moving into sorry, moving into, how would we write a program for this, this medallion. And I want to talk about periodization as a whole to help understand how we're applying s. And for those of you that aren't familiar with periodization, but it's basically the ebbs and flows of sets, reps, and general exercise volume in a given calendar year or competitive year. It's largely in the strength conditioning fields, but I think as movement experts is something that we certainly, probably apply and we don't even realize it or where we do realize it sometimes in our rehab setting. But early on the volume is high, the intensity is low. And by the very end of the even the rehab program are ready to discharge. The intensity is usually higher, volumes usually lower. If you consider like an ACL returning this sport, you're doing heavier weights, lower repetition ranges, probably less exercises in that sense. And the same thing kind of applies to be a far as b if r and out of the gate is the me who apply to someone that's in pain, someone that's a mobilized and it's usually high volume. Generally consider low intensity because of the repetition max. The other thing I want you to think about here though, is this periodization cycle of reducing volume. It's also true in terms of how many exercises of blood flow restriction training are you performing? So over time, you should be doing less volume of blood flow exercises and more intense exercises as you go. If I try to write this out in a little bit more clear fashion of, you know, what are the program goals if you're, let's just say the cases dealing with symbol with an ACL reconstruction that you're probably coming out of the gate in your training. More muscular endurance, trying to work into hypertrophy, trying to work into strength and maximal power. Does rep schemes would look like 12 plus repetitions early on. Six to 12, ideally in the hypertrophy phase one to five and maximal strength and kind of our face. I know these Rep schemes aren't the best solid science and Brad shown fellows dumps it. Interesting studies of how you can get hypertrophy gains at, at variable repetitions, which we've obviously seen with blood flow restriction as a whole. But I just wanted to make it some concrete examples. And in terms of periodization, there's also program design and the order. And the way things typically are organized are a warm up skilled worker plyometrics, which probably is not always going to occur earlier surgery, I hope not. In our, our patients, maybe the end stages. Then strengthen your compound movements and then some accessory work or single joint exercises. And what you can see with blood flow restriction and why it's such a great treatment form is addressed is a lot of things very early in the rehab process. It allows you to do compound admins, allows you to use single joint movements. It allows you to strengthen pretty early on. Even know someone's in a lot of pain, which is great. However, it doesn't address these, these bigger things that the maximal strength and power deficits, which again, I keep hitting this is if you can train them at higher intensities, please do. If the need is still there and you've assessed to say that the need is still there. An example program here again, use net ACL example is, you know, your manuals and excuse me, a warm up period might be manuals and stretching. You may still have some mobility deficits to address. Your skill work could be or your neuromuscular control, your balance stuff, as you can see, working down here. Than your traditional strengthening, your compound movements could be your leg, press your wall, sets your single leg bridging. Now I'm not saying that closely and exercise is the better exercise as you know, for many people from, from Delaware, we do like our open chain exercises. I'm just saying that in the concept of this example, it would actually be the exercises that you can train without pain that are not limited by pain. And then your accessory or single joint work is you'd be FR and b if r is not accessory work. But for this example, in the order of performing it coming last, That's how we're using b if r. So my simple point is performed blood flow restriction last in your exercise flow because it's going to challenge the muscle to such an extent that could interfere with all the other stuff you're doing, your balance control, your heavy loading for other exercises that you can perform at 70 to 80% or more of a one rep max. You shouldn't be doing blood flow restriction training before that, an exhausting the muscle and then trying to perform high-low training. I think the only caveat it against is the grey area of PTA until you find a reason not to perform. It lasts like the examples I gave up. Its giving your patient acute pain changes very early on. You now could be a reason that maybe you apply it first. But for most things that we are a teaching to simplify application is performing it lasts for performing it with the exercises that are limited by symptoms. So how do we use it in terms of frequency and duration? Again, we broke it down to two to three times per week for three weeks, greater than three weeks, that this is based off current evidence that we can see some form of change potentially in this time point. For strengthen hypertrophy. Ideally, there are some other guidelines that were given in strength. If you can use it for eight to ten weeks and for hypertrophy pretty standard four to six weeks. But I think as clinicians and insurance visits, that's not always feasible, particularly the eight to ten week range of two times a week. That's that's almost all the visits you're going to get. But the reason we brought up that the two or three times per week for three weeks is those are the intervals. We're deciding if we can see change. We're going to either a, re-assess if they can start progressing to higher load training or B, we're going to do a strength reassessment and see if the goals have been achieved. The last piece here is that I'm not gonna talk about too much, but aerobic exercise is another form of using blood flow restriction training, like cycling and walking actually has been shown to give strengthen hypertrophy gains as well. Kind of falls in the same realm of a six-week ideal period. So how do we use it in terms of our adjusting and some tips of our clinical application very for were having issues with completing all the repetitions. First is adjust the rest periods for probably the first actually is adjust the load because you could get off gets not perfect science. But after that, if they're still having issues, adjust the rest periods from 30 seconds to 45, and then continuing on. If they still can't complete things, then you may have to adjust the occlusion pressures to, we're picking only one variable. We're making that change. And that's it. We're trying to make sure we know why it's not successful. So we're not applying different objective changes in energised guessing. So they can't complete the reps trying to reduce the pressure by 5, 10%, definitely 10%. If it's actually because of cuffed discomfort, that CAF can get pretty painful. Sometimes. Often it should be wide enough. That's not very common, but if that's the case in or completed that we do drop it to 10%, but trying to stay within that minimal dosage to of 60% for the legs, 40% for the honest. There can be a suggestion to measure them in the position that their exercise and infer the limb occlusion pressure. So when occlusion pressure is basically when you hit start and that the oughta regulating tourniquet system, it measures 80% of what? A full cutoff of blood flow, the arteriole. And that's what it chooses to exercise at. And I'll show you a chart in the next, the next slide that we got from one of our weekly emails that we get from Johnny Owen's group of that you may need to change it and go even below that 60% rep rate or occlusion range. Excuse me if your exercise and standing up, I'll get to that in just a minute. But the last piece here in terms of adjustment and tips is just keeping an eye on the speed of repetitions that your patients can pleading or they, are they actually going to slow? Is that why they can't complete the reps? Are they going too fast and you just didn't pick up on it and even overdosing the entire time. And that's why we're trying to keep that criteria very strict. We can rule that out as a as a potential reason for why they're not able to complete the reps. And then finally, we haven't seen compensations with bilateral US, excuse me, with bilateral exercises. And there is some evidence with this to that because the muscles getting fatigued over time, they're going to start shifting their way to the other leg. And you seemed away if that's even a good application of blood flow restriction training, ACLs we know for up to six months they can try to compensate with bilaterally use. So it's even worth doing in that population. Also one of the reasons why we're only doing three or four exercises as a whole and really trying to isolate it to what is limited by pain. So here's this Lynn occlusion chart that we provided. And you can see here the supine exercises is that this is with the legs. This is the standard 60 to 80%. But as you become more upright, that pressure that you may exercise should be dropped. So depression. So it's not as uncomfortable with the cuff. This is I'm just providing it to provide it. We haven't made a distinct change in how we're doing things because of this. And we have some issues with the regulating tourniquet system calibrating if they're doing it standing so and providing that as a resource if you're able to do it in your clinic, great for a thing to try out if you're having issues with patients dropping always below that 60% range because they can't handle the pressure to cut. My favorite part, this is where I think I heard out a little bit of how we try to get off it. Is, can your patient exercise at, at or above 70 to 80% of their one retina. And we know as therapists, we potentially are guilty of under dosing based off symptoms, which is tough because it's hard to gauge what the patient's feeling, but we're not talking about 70, 82%, excuse me. Let me just back up for 1 second. 70, 80% is roughly around ten to 12 repetitions. Maybe a hair less too dependent on the chart. So 70 to 80% or ten to 12 reps does not mean just completing them. It means doing a weight that will have you fatigue or failure, or fail, excuse me, at ten to 12 reps. So a breakdown in technique, pace, range of motion or whatever your criterias for that exercise. If they can do that, it's time for them to go into high intensity training. Get off B if R for that movement. The next piece is the weaning might occur with individual exercises, not the whole program. That's why I wanted to share the periodization chart that early on, the high volume of blood flow exercise might be four exercises. In after a few weeks, it might be one. So close you and exercise. What if they're having less symptoms with to tell a femoral pain? To me, their telephone demo panel is present before. Are they having less intense with closed chain? Can they exercise at 70 to 81% rep, max? We should probably move away from blood flow for closed chain. But what if they're open chain exercises and we're trying to improve their Quad strength is still causing high symptoms. Now I'd say keep using B if R for that that case, unless you know that strength is already being addressed with closure. Has the ceiling as the seal even exceeded by the exercise. So this is that functional example where if I'm doing blood flow restriction training with someone doing step up some and they don't need to do more than a two step. I'm not going to keep putting them up on 1012 and step-ups they may, if they're doing 75 Rhapsody, eight inch step up when they started at four inches. And when you're done, like that's it, that they can use 75 reps as I mean, what five slipped by six flights of stairs. That's the goal. We're doing just fine. And then finally, had the strength deficits been addressed. If we are trying to reassess at three-week intervals or every six to nine visits or we just done had they actually issue there straight goals already. Then I know I said that high intensity training outperforms blood flow restriction trained, but it does improve strength. You may actually get ringing to get just the application of blood flow restriction, but you have to be reassessing. There are some recent studies that show that actually has equivocal results to high intensity training. But the only thing I want to bring forth there's those high intensity training percentages were 60 to 90%, which is basically the entire spectrum of all all weights and repetition. So it's not as specific as the prior example I gave of at least 80%, but that the strength deficits have been addressed. It's time to move on. Alright, so the final pieces here are what is the typical vital response or physiological response. So you can know who applies for safely. With blood pressure. We know it'll increase during exercise. This and for any other form of exercise with blood flow restriction and it'll decrease post exercise. You're a volume reduces, which generally makes sense because the occlusion that heart rate will increase. But overall there's no change in cardiac output. Patients. More specifically though, compared to non, this is only a non hypertensive patients. We do see similar systolic responses to greater than 60% of a one rep max, which, which would make sense, right? This is email, it's lighter weight, it's generally more intense because of the perception of it. So we're having similar systolic responses. However, after exercise we're having a hypotensive response. So people that aren't hypertensive, fine. But if they have hypertension episodes, you may want to keep that. You may need to keep that in mind. It this is someone you need to be applying for. Are you need to talk to their physician, which is why one of my assumptions was any precautions that you have, we're getting approved from the physician because we don't want an adverse event to happen. And we've had a couple weird hypotension episodes with like students practicing on themselves for whatever reason. So the other thing is the heart rate will increase at similar levels to high-low training, which we know that you should have rate increased, but people are tachycardic humanity consider if it's appropriate for them, if they're cardiologists is on board. And then lastly, if they are hypertensive person with hypertension, excuse me, it does increase at a higher level than to 70% of one rep, max cohort. So that is a precaution that we had a somewhat is hypertensive is on medications. We are reaching out to their cardiologist or primary care to get approval if they are considered in a pretty heightened state of hypertension. In terms of hemodynamics, DVTs, and things of that nature. You know, there's not a lot of evidence that exacerbates that that process. There it actually may help, but the evidence and this is limited. It's growing. They're really trying to see if there are adverse effects in terms of DVT risk overall, most of the studies incident has been extremely low and they're trying to study it. And complicated patients with co-morbidities to see who this, who would most likely have a DVT, such as dialysis, femur fractures, joint arthroplasties. So they're doing their due diligence here and I'm maybe Johnny has more info on that than I would today. But that's something that we're considering two in our patients that if they do have a DVT history in the past 12 months, I believe that the contra indication here, I have that on the futures. What side effects should you know? We'll be talking about hypertension. We talked about hypertension being a risk factor or precaution, but there are some rare but minimal rhabdomyolysis events and I'm very rare events in there. I just thought I'd mentioned it because it has reported. But the more common side effects are bruising, Contiki, a muscle soreness, a muscle pompe or like a swelling feeling in the muscle and tingling in the distal extremity with US. Tingling is okay. Numbness in the distal extremities not eat and turn off the cuff or lightened the pressure. Anecdotally, we've had headaches for patients with concussion history's not sure why specifically, but something that we've we've just been trying to note. Here are the precautions they provide for you guys. So you can have have those camera defining to shoot out those couple of slides, precautions in the contrary case. And then just going back to these case examples with the last few minutes that I have. This is the MiSeq dummy patient here that was having the severe arthritic changes and an inability to walk. So I mean, out of the gate here her her clot index was 67 per second. I just wanted to take note of her her involves side being 80 Newton-meters. She also had some knee flexion strength deficits that was not limited by pain. Very low chaos, very low key SFS, 30 seconds at the stand well below age match, six minute walk test isn't too bad. But her stair climb tasks was was pretty slow. Just up and down one flight of stairs. And, you know, what we decide to do pre-training was she had to strength deficits or quad and she was limited by pain. So we did long arch should be afar. We did sit-stand BY FR because she was having issues the closed chain movements to we did some isometrics, multilingual isometric CPFR because again, we're restricted by no weights, no heavyweights, and no machines. So that's why CIT stands. Isometrics and long arcs were included and we got some clearances to adds to light weights for B FR. We did not do be afar for hamstring curls. So he did some standing knee flex you with weights there because it wasn't limited by pain. Her steps we didn't address would be at far she was having such significant issues. We actually put it on our altar G. Try work that a little bit so that could be a confounding factor to some of our results. And over time, once the docs all the progress she was making, we got clearance to put on a leg press. And the first thing that she was improved upon was her sit the stands became non painful, so we moved away from them. We moved away from b if r And we did heavy E centric leg press per the 70% number one rep max at an acceptable pain level after MD clearance. Once something improve be weaned it but longer stayed with BF arc as she was having issues with those. E here is the first three weeks we re-assess six visits. Really a slight increasing QI, but it's a fake increase because her other side went down. Involve side didn't go anywhere. But after six weeks of application, she had a 106% quad index. O sides right? The left to the uninvolved side is stable. The other side I increase quite a bit. And the big thing to note here is we never went above ten pounds on long arcs for blood flow restriction training. So we really didn't even do very much heavyweight. We did end up getting to essentially leg press for like two weeks before that testing. So not the perfect evidence of it was albeit far are one thing, but that's why we're just we don't really care. We gotta there within what we need to do. Knee flexion did not improve. And I wonder if it was just because of the limitations, would not be able to use machines in the appropriate dosing if we should've just on GFR the whole time for that because of what the restrictions were. Then overall, outcome measures and functional testing significantly improved MS doubles at the stand and stare contests, cutting. But it is having two year old male with knee pain, arthritic changes, very similar findings and knee flexion, but this was limited by pain. His QI was a 101% from the get-go, said no actual strength deficits there. But obviously you can see significant limitations in function per self perceive function and functional testing. So he also had some He'll raise strength or deficits because he had an Achilles repair. And can we do like one or two, but that was not limited by pain. So his program design was actually hamstring curls width b afar to start because it was pain limited. Then he did he raises without blood flow restriction, heated terminal knee extensions without blood for restriction. We did those largely because ism is gate to gate deviations we saw. But then everything else in terms of stiffness stands, step ups in a walking program was with be FR This was the guy was like try anything please. I don't want the total knee just yet. And we were trying to regress all his functional complaints. Has SYT the stands, his walking and his stairs to a level that he could perform with. Our symptoms are minimal and apply to be a far cuffed to make him work harder, hopefully to get some acute pain changes. Just by saying that what I forgot to mention evidenced wise with the acute pain changes, there is evidence that there is endogenous opioid release and something going on metabolically for why those pain changes occur. So we're not just seeing that, we're seeing that clinically, but there is something going on that they're evidence is starting to show two. So with this gentlemen, over time, we weaned from b if r for the hamstring curls, we mean from things with a sit to stand, so we continue with the walking program. Then again, deflection didn't changed. That just makes me wonder ecologist under does nasa therapists on that one for sure. Once we got off at the GFR, but he actually had pretty big changes in strength even that he got even stronger on that side. So is that why he was feeling better? Because it's chaos has improved. His PSF esters improves his functional testing was was better, not perfect, but someone that we probably knew we weren't going to get perfect recommendation was for a total knee and he just wanted generally to feel that he could hold this off a little bit longer until he was ready for the surgery. And the last one here is the simplest one. I think it's, it's very interesting, but this ACL telegraph came in with UI of 13% at six weeks. She's walking around without a brace. It really not good. And it was largely limited by pain. For weeks later after only performing long arcs, egocentric long Arts with a blood flow restriction cuff, we maxed out at 12.5 pounds at most. And we just did terminal knee extension, single egg stand, straight leg raises, and some hamstring strengthening without be afar because it was not limited by pain. So again, with that with that concept, if its not limited by pain, we are loading that as much as we could or trying to train it. Just doing this, she ended up getting up to 78% in four weeks with only doing 12 pounds at max of Quad strengthening. If you really compare that this number to this initial one, she's actually the Route 87%. So her other side increased as well, are uninvolved in, as I said, is that the systemic changes that are occurring, maybe is it just that she's exercise? And again, I think that's also a possibility. But that was just another case example of how we've really just tried to apply blood flow restriction train to the areas that we're most painful. As soon as she ended up reaching that range, obviously, she's not paying limits in anymore. If she's pushing out that much, we moved we moved away from it and just continue to try to address her strength deficits with higher led training. That is a and I'll take any, any questions if anyone has any thoughts. I definitely thought I was a great presentation. A couple questions regarding, I guess, what's the percentage of the patients that you will use blood flow restriction in the clinic because obviously you showed the evidence behind that. And then how do you do you ever measure like the psychosocial barriers like potential pain catastrophizing that a patient may have and how we implement that in your treatment. Yeah. So in terms of percentages, I said there is an Evan flows at 1 as soon as I had to implement best pupil files, appliance it to everyone, but I just had like three people at the same time and in any case, in a in a certain cycle of a day. So I would say right now it's probably under 10% of our patients that I know I personally apply for. I think I can speak that's pretty similar across the board. It's definitely not a high majority. It's pretty low. And then in terms of the psychosocial factors, yes, we do measure that. We have we usually with knees, we get the Ts k. For most our knee patients that come in, it's usually attach the K west and Early on if that's if that's the case of we think they could be limited because of their fear. We usually have some other methods to before going be FR to try to apply. I wasn't sure if that's what you're getting at. If you would use b if R for that group? I've I think yeah, I wouldn't disagree with that. I think there's something to be considered there. They can exercise successfully and it changes their pain perception than, than great. I know the study that I mentioned briefly there at the end of how it changes, there is a change in opioid or endogenous opioid release. The question that pet paper raised was, how does this apply to our chronic patient populations and pain populations, excuse me. And they didn't know, but maybe it's worth future research. So I haven't said that specifically apply it for that group. We usually tries to mother PIP2 or psychologically form physical therapy methods first before doing that, since that's where the the evidence seems to point. Cool. Thanks, friend. So I see there's this can have great potential for bariatric clients who have severe knee arthritis. Have you dealt with any clients in that realm? And the other question is, do do the cuffs of comedy march clients? Yeah. So good question. I think I'm not going to lie. I think the biggest cup we have there is some limitation to application for sure. I don't think we have a strict cutoff for that. We haven't given recommendations like, Hey, there's a certain limb size or body weight that that it's best applied for. But I know I have had some residents come to me and say like, hey, I'm having a difficult time with this, this cough steam proximately. So you know, I think that's a fair point out. I don't Johnny may have more information if there's if there's other adapted costs that are being developed, that thing is certainly to keep in mind for the art for their arthritis groups. There there is some evidence coming along with that that it can be helpful. I think what we know it does groups in general is sums, sum graded exercise is helpful as a whole. So I don't know if that is just tapping into that piece of it or if it's addressing a lot of factors that we're still trying to figure out with blood flow restriction of. Is it changing this, this opioid release? Is it in fact improving muscular function? But we know we've, we've been trying to apply it to those groups judiciously if we feel that they meet the criteria of being limited in their addressing their impairments with pain first and then if we're just not getting anywhere in the Patients Like I'm still not ready for the next phase. That is a joint replacement. We would move into this. Alright, we'll try it for everything we can with a walking program or a general graded exercise program to write. I mean, I'm thinking even just for a better outcome with the total knee replacement. I I know somebody right now who is severely obese, but because of her knee pain, she doesn't walk. It hurts to exorcise and she's getting weaker and weaker. The doctors don't want to touch her because obesity add weakness. I mean, it's a bad combination. So if we could get her stronger yeah. And, you know, she can do her best with losing weight, but she's stuck in a wheelchair right now. That's it. That's a great point. And I think one thing I didn't touch on there and I think maybe maybe I'm site GI hopefully Johnny touches on everything right, that I don't have any more. But there, there are genes that there has been shown that people's VO2 max does improve with Arabic trainee with this tool, your training at a much lower intensity. I think that might fit that population you're talking about. There stays H2 of here. There's multiple factors for why we have arthritis changed. It's not just wear and tear. And also that the functional spiral that people can go into it, that, that how you have to start somewhere. So I think certainly it could be a definite option and that's why they're studying these groups that are on dialysis or femur fractures is see like, hey, how can we help these people out that we really have trouble getting kickstarted? Interesting. Infrared LED around. Hey, first of all, I really enjoyed your presentation. Thank you. I just left my gym, so I apologize for my parents. Just curious. I've I've a patient too. Her his hamstring, muscle or tendon disjunction Area, Substance biceps femoris like two years ago and the columns across and as qualifying for, you know, brains, OCS. And really nothing has gotten him took place, unable to rubbish, does a lot of pain. Just work through it? As curious. And he can't get strength. He just been like 30% deficit. We just cannot push it. Well-tolerated. Some piqued my interest to give that a try. Just didn't know if you've encountered anything like that with or read of anyone use it for product, hamstring. I'm injury. There's a pretty bad one that I probably shouldn't operated on what had happened, which rarely do that bad, but just just curious. So we've kind of done everything. Yeah. Personally, I haven't had to work with anyone and using it in that sense. I think what you said there with it, what degree of the hamstring tear wasn't interested and operate in the first place is the first thing my mind goes if we're ever going to get it back. But in terms of if you just take that big picture away and you say what is impairments tell you that these limited by pain, you can't get the strength that that might be someone that it's worth, the shy, it's safe. In some of the tendon. Some of the tendon literature on this is, is interesting. And the fact that we know tendons probably adapt better to load. And this is something that seems to D load a tendon. So I think there is some debate of, is it best for applying to that cohort because we want gradual, progressive increase in load even in the face of pain for any tendons, even a muscular tendinous junction issue. And then there's some, there's some studies coming out that they're doing this looking at people with tenant issues too. So I think that's probably going to be developing here in the future. Definitely out of my scope though with where Work that's Karnes dealing. I know they were there into the the focus of load there, but if it is the muscular stuff, yeah. I mean, bear game if its came limited. Just like I had to have been able to get some hypertrophy mobility. Doesn't that are a little bit bigger motor for him to build a puncture atom, so a urea. Alright, thanks Fred. I'm awesome presentation. So I'm really interested in what your thoughts are behind using enemy S and B, f are together. And I noticed in the last patient, the ACL patient, that that those two were combined. And so if you could just kind of speak about the current inking behind both those modalities and be great. Yeah. So I mean, we lost him in the quad and I hey, we've gone there, so we, we do, we do it for a certain reason. So we have R and B units. The old ones are dying. So we have these newer MP units that don't seem to have the kick that our old ones have. And we typically apply enemy asked to try to get someone to minimum of 50% of their MBIs steam maximal contraction with Justin. Now these units for some reason, some of them get in there and some of them don't. We've had patients that we, we literally max out the unit. They get a great contraction, but it's still like 10% of a, of a FDIC. And we went off what Johnny was teaching us of you. We are using b if r and enemy at the same time to try to trains with the same concept. While if you do it for strengthening, why can't you do it for enemy yet? So if someone can't get to threshold, we're applying BY FR for some cases at the same time. So in that case she was someone that was only getting a 10% threshold. We max out the unit. We had no way to get more out of her. And we know that we want to get as much out as possible, base off the evidence. So we said, OK, let's apply BF are that same concept of will stay within working into lower threshold, but hopefully we're getting the similar response. So it, it, how does it feel doing HIV? Patients have been surprisingly okay with it. I think they're just confusing. They're not sure which one they they like more of the enemy S or B if our cuff on. And I'm hoping to see a case study or maybe something I'd CSM cell. If you if you have anything coming out, let me now. Yeah, I will maybe I should start tracking the cases that we're applying it for and and we'll see how we, what we get from that for sure. And it doesn't look like there are any questions. Anybody else any other question? Okay. We are on break until 1130. So we'll see all back then. Was recovery science a corporation reckon, are recognized in the Inc. 500. You manages a portfolio over 400 clinical trials being conducted worldwide, primarily studying the effects of blood flow restriction in clinical populations. Use the former chief of human performance optimization at the Center for the intrepid at San Antonio mil Military Medical Center and continues to serve as a consultant and clinical research there. Completed his undergraduate coursework and biology at University of Texas at Austin, earning his Masters and PhD at the University of Texas Medical Branch. You serves as a medical consultant for teams and NFL, NBA, Major League Baseball, NHL, and collegiate sports. He is involved in numerous clinical trials involving regenerative medicine, sports medicine, blood flow restriction, and high-energy trauma. And he's been published extensively in the peer reviewed literature, regularly speaks at national and international levels for his work has been featured on 60 Minutes Time Magazine, NPR, Discovery Channel, and ESPN. Once again, if you guys have any questions, feel free to reach out on the chat log and me or gene will take care of it. Thank you. I guess kind of renewing our share screen now it's given me the option. For Harvey. Absolutely. Okay. All right. You guys are probably piggybacked, Erica. Sorry, I had some block on my zoom for some reason. Alright. Garbage. Yes, sir. Okay, Cool. Thanks. Gary and I definitely don't have 400 clinical trials or my portfolio. I think it's 40, so I would never want to have 400. I'd pass out and dies. But anyways, thanks. Thanks for having me guys. Good morning. Saturday morning. Last time I spoke with Delaware was the end of February. I was at the University of Delaware for their conference and that was one of my last trips outside of Texas. Since the world has changed a ton since the last time I was I was with Delaware. So hopefully we're getting back to what it was like earlier the year now they were all back together. So I'm going to talk about blood flow restriction and kind of give some updates on where we are and what we know currently and maybe where we're going as well. And hopefully I'm not repeating a lot of what Fred said that if I do that, I apologize. Alright, and just kinda get into the nitty-gritty here, what blood flow restriction is? We've always had a problem physiologically in rehabilitation that a CSM guidelines for streak and hypertrophy say we need to lift at least 7585% of what one rep max. You need to do that for months, three to four months to typically see changes in muscle quantity and quality. And our problem obviously is in rehabilitation. Obviously, a lot of what we say is for strengthen hypertrophy kinda flies in the face of what we know physiologically. And so we use light loads. There's no ACS M guideline that says if you can't lift heavy, go ahead and just lift light if you're really trying to make changes in muscle. So that's, that's always been a problem that we've had and that's where but-for restriction has been so kind of exciting because it seems to bridge this gap where we can't do heavy lifting because of injury or, or age or pain. But now we can still if light like we always have and still see results that are similar to lift and heavy. So I'm sure afraid probably went into what blood flow restriction is. So I'm not gonna kinda go deep and every little, every little point here, but in its essence, but the restriction is the application of a tourniquet on the proximal thigh or the proximal arm. From a placement perspective, that's very important because turning kits are made to go over the largest muscle groups. And unless you have these very specialized turning kits for certain surgeries. So if you ever see someone doing blood flow restriction and they have cough down below the knee or down below the elbow? I would I would definitely correct them in that because it's known in the in the surgical world that attorney kid down over those regions will take out nerves. So you can take the fibula nerve very easily if you put a tourniquet down below the knee. So it's all plumbing. We're just we're just blocking the vascular and vascularity with these things. So put them up on the most proximal regions is not only safe, but, but that's the FDA's listing for you supposed to do when you turn it gets when you get the tourniquet onto these individuals, we have to determine how much pressure we're going to apply to give blood flow restriction. And so what we use this term called LLP limit collusion pressure. And LLP is basically the percentage of what full occlusion is. So we use these systems that they have these kind of built-in Doppler is it will tell you what a 100% limb occlusion is for each individual. Every individual, it's different. It could be based off a variable, could be blood pressure. The size of your limb is a, is a, is a huge variable. How much muscle to adipose tissue you have is a big variable. How wide the cuff is, where the cuff it's placed. All of these play into it. So there's no guess. You can't use something like systolic blood pressure because blood pressure is just one of many variables. So Doppler is the gold standard. And in these proximal Doppler embedded in these cuffs or are really the ultra gold standard. So we take them up, you get a 100% of what's limb occlusion pressure. And then the majority of blood flow restriction is done allowing arterial inflow. So we want to back it off of whatever that a 100% is. There's, there's some, there's some. Applications where we do use a 100% that they'll touch on a little bit. But the majority of time we want to allow arterial inflow in the lower extremity right now. We we kind of feel pretty confident that if you're exercising with a tourniquet on 60 to 80% of this limb occlusion pressure kind of seems to be the minimal effective dose and the sweet spot. And most of my clinical trials we start at 80% limit collusion. If a patient's can't tolerate it, we drop them Downing and kind of bottomed out and stop at 60% of they can't go below that. In the upper extremity. It's not just tolerable to take those higher pressures. And so what we've seen is that 50% limb occlusion pressures much more tolerable. None of this matters if the patients can't get through it because of the ischemic effect and just the overall pressure. So what we found in the DOD was 50% was tolerable. And we're also getting similar results when we're looking at our streets and hypertrophy scores as well as some of the acute measures. And just to kind of piggyback on some studies that are helping to back this up. Jeremy Lin, who does a ton of work and an old myth, has been looking at pressures for a while. And he, and he showed us when we first were he was a consulting with us at our, at our center that when they did 40% limb occlusion or 90% limit collusion, the upper extremity EMG signals were really almost the same and different enlarged frame. It's really interesting. But in also in a chronic model. So then when they took it out on, did eight weeks of training, they saw for muscle size and for muscle strength, 40% did just as well as 90% and they both had significant gains. And so we kinda just made it easy. And 50% seems like it's an OK target. That's for strengthen hypertrophy. You know, there's some interesting things we're getting to the point where we might be changing pressures just for wet. Our reason is of doing this. We're really looking at can we improve vascularity, especially in elderly individuals? And Jeremy's group showed us that 40% helped with endothelial function in the upper extremity. But you've got 40% did not help with it, but 80% did. So. And some of these applications, if we're going after or maybe a bone does not healing because we want to get an angiogenic effect. We might have to look at pressures differently, but from strengthened hypertrophy of the upper extremity, that's where we live. This is a VA, study than the lower extremity when they looked at the vastus media Alice and the rectus femoris, only 80% limit collusion really had the highest EMG activation the entire time. 40% limb inclusion just didn't increase any muscle activation at all. When you're doing blood flow restriction, you are basically choking out the Krebs cycle. So you do this high volume first set of 30. And what that is, is the muscle still full of oxygen? It's usually easier. When you're doing it at a low load, you still have Krebs working in it and it seems fairly easy. Your body always, always, always wants to use slow-twitch fibers first because it Can you slow twitch fibers and not give you any reward for that. The body doesn't like to just give you muscle, willy nilly, because the more muscle you give it an individual, the higher their metabolism goes. Because protein synthesis, which is what muscle goes through. Requires ATP, so your body really makes you earn it. So when you're looking at these EMG signals, that first set of 30, you usually don't see much happening. And then as you move into the next set, which is usually 15, Now, there's not enough oxygen on board. Krebs is kind of like I'm done, son and you are still using low, low, but now you're forcing them to recruit more and more fast-twitch. So your fast-twitch, those are bigger motor units. You'll start to see EMG signal goes up and then you start to get these byproducts of anaerobic metabolism. And that's what this study showed. Set one here you can't really see much biceps here. You're already starting to see those fast-twitch fiber set three even more set for 40% did nothing only on the basses media Alice they, they did see and 80% itself. And so I'm kind of known as a high pressure guy. I think 80% in the lower extremities where to go. And this is from a really good lab in Australia, Stewart Washington's lab. In way he showed recently was that if you did a low-level exercise or 40% limb occlusion pressure in the lower extremities in all his markers that are important to us but lactate, so a really easy one because whenever you, you use fast-twitch muscle as you get in the anaerobic metabolism for every glucose molecule that's used in that, in that physiology, you cleave off a couple lactate molecules. So someone's in anaerobic metabolism using fast-twitch fibers, you can usually just get off pulled blood lactate read and say, yep, you were there. He showed at low-level or 40%, there just was no change in lactate at all. At 60%, they did have arise in signifigant rise at 80%, it was better and then lifting heavy was the best of all. And we always say that if you can lift heavy, lift heavy. Heavy typically wins when they're wet or you're having a head to head BF arbors heavy, a lot of them. We just finished a hamstring study at USC which showed they were almost the exact same, but typically lift heavy if you can do it. Anyways, back to this. What the overall conclusion was from Stuart study was that 60% is the minimum will be FR pressure. However, 80% you're probably gonna get augmentation of what you're going after. And I just want to point out, and this is an open access paper that we did in Frontiers and physiology. So this was a working group of BF are researchers from around the world. There were me and Jeremy, Ole Miss were the two from the US that are on this and put a position stand out there. And we also put that out that, you know, we need to mentor and he's limb occlusion pressures. Just throw in a cuff on willy nilly and guessing is not the right way to do it from a research perspective or a clinical perspective. It could be dangerous or you could be not given someone an effect because you're just not getting enough occlusion, which we've seen in a lot of studies. And just, this came out actually two weeks ago. And it's pretty interesting early on when we were really trying to figure out how to do this in a DOD, almost all the studies we're seeing the use what's called an arbitrary pressure. They say less issues 200 or let's just use a 150. And that's just really hard. If you have a big limb, you might be at almost no occlusion. If you have an elderly, smaller lamb or Euripides, They might be where they're getting no blood down there at all. So we we started at around 2010 and the DOD starting to put a call of let's let's personalize this. Let's start using somethin to look at LLP. And now if you look in 2018. Llp is really taken off and from a research perspective, that's what you're seeing. It's much higher I think than this because this review only to studies that were at least two weeks or longer, there's a ton of BF are studies, there are acute models and physiology labs that are using personalization. So the researchers go in this direction, use LLP and clinically we're really going in this direction as well. So getting back to this slide, typical set and rep scheme is four sets, 30151515, 32nd rest kinda seems to have the biggest effect size. And that's what we call the gold standard for blood flow restriction sets and reps schemes. And so must of us use that model. Sweet spot for how much load is typically 20 to 30% of a one rep max seems to just be where buffer restriction does the best you can use no load at all. And we still see changes, but you're going to get more of an effect if you get 20 to 30% once you start to get higher than those loads and people are like, what if yield is lift heavy and do it with this. Typically, it's just incredibly hard and you just can't recruit enough muscle. I, I've seen plenty of of players and street coaches just, just bottom out after one set. And so we, it's it's a low load game, which is perfect because that's what we do in rehabilitation. You reduce the flow in the artery. Arteries are thick, they have muscles that we're basing our but-for restriction off of the artery. When you do that, like I mentioned, you're gonna see increase in muscle activation. As you increase muscle activation, you get what are called muscle metabolites. That's lactate and that's the acidity that you get that burn. That lactate is a signal, we used to call it muscle waste products and now they're called muscle metabolites at ACS sam last year, keynote speech was the lactate shuttle theory, which is basically how important lactate is for so many things. So it's not a waste product. And what that does right off the bat is it stimulates the pituitary gland and you'll see things like growth hormone will start to spike just because we're able to manipulate that large load of lactate from anaerobic metabolism. Then there's a whole bunch of downstream effects that I'll, I'll go into a little bit. Insulin-like growth factor, which is a regulator of muscle mass goes up. Vegf, which is a regulator of bone healing as well as angiogenesis goes. We get a proliferation of stem cells. We have a paper coming out with the andrews institute showing that you can do this and increased him sell load, which might be valuable for things like ortho biologics. In the real target, which I'll go into a little bit deeper as muscle protein synthesis that's at our military was one of our key things that we wanted to go after. The vanes are more pliable. They're not thick and muscular like an artery. So you completely block venous return whenever you do this. And so when you block venous return, what happens is all those Muslim metabolites don't leave. They're just blocked in the limb the entire time, even during the rest period. So during the rest period, which almost as sucks worse in the exercise, you're just feeling all those muscle metabolites blocked. And what that does in as we keep that lactate load in there and we keep that lactate load really high, which we think might be valuable for some physiological parameters. And I'll get into it as well. We think it might be valuable to get some pain relief from this. Muscle swelling happens in muscle cells, swelling happened some, there's some thought that when the muscle cell swells, they are stretch receptors on the cell wall. And when those stretch receptors get stretched from the fluid pushing into the muscle cell, that increases muscle protein synthesis. There's a lot of debate, but a lot of people feel like the swelling effect is actually pretty valuable to hold off atrophy and then you decreased stroke volume. So when you block venous return. Cardiac output equation is stroke volume times heart rate. Stroke volume goes down, heart rate goes up. So when you're doing this, you, you get more of a cardiovascular kind of workout because heart rates trying to maintain cardiac output. But it's really valuable for things like walking on a treadmill or spinning on a bike when you're going after this cardiac output equation because you can have them at almost no resistance on a bike level too. And it feels like they're like the level 11 just because of that decrease in stroke volume. And we've seen an elite error rescuers and the military college basketball players and healthy is that we can do these low, low, low level things like walking or low spitting on a bike and an increase in VO2, which is pretty cool to see. And then lastly, gene expression. Gene expression is where I really geek out on what we're seeing with blood flow restriction and we're standing on the shoulders of giants here. So last year the Nobel Prize in physiology was given to these three gentlemen, one from Hopkins, one from Oxford, and one from Harvard. And what they have done decades of work is showing that if we can reduce oxygen levels around the cell and you can really manipulate the cells gene expression in a, in a positive way. And one of the real fascinating things was hypoxia inducible factor one a hip one a is just this amazing thing that is, you take oxygen down, it just sets off all sorts of thing. It can be neuroprotective its way increases VEGF, which we can create angiogenesis. So we're seeing a ton of work from some really high-powered labs of how we can manipulate oxygen and see these positive effects. And what's cool is we're kinda just following these great minds with what we're seeing in rehab. And that's cool. There's so many things we haven't rehab that are done with really small kind of lame clinical trials or they're done and we just don't really have a science-based background. We can say with this, we got some of the brightest minds in the world who are giving us this science-based background. And with that I'll say blood flow restriction. I mean, if you if you Google Scholar this, your head spin and how many papers you just constantly flooded with my full-time job. I feel like he's just trying to read all these papers. This is my mike bib list where I keep most of this stuff. Not all of them RBF are, but probably 90% are. And it's about 15 over 1500 papers. And we don't want to go through all of those. But if I just did a search for blood flow restriction, systematic reviews, we do have 32s to some meta-analysis that had been done. So that gives us kind of a nice overview which we can kind of look at. This was one of my colleagues up in Canada, Jamie's group who didn't want to do a systematic view them analysis, just looking at all the healthy individuals do in blood flow restriction a load versus low load extra dies. And pretty much everytime you compare load to load with a tourniquet on the tourniquet always wins. And that's basically what he said. Cardiac since yesterday. Addition, it'd be FR augments the changes and muscle strength and size. And also what was in their conclusion is, these changes happen in a fairly short duration if you're doing it right and some people just don't respond to it feels like frequently anything in life. But if most people When you do this, right, we see results sometimes within a couple of weeks. Our first case series, we put out a bunch of special forces injured service members with this, within two weeks we saw a pretty dramatic, dramatic changes in their strengths. So this isn't like you have to do it for months and months. I think if we do it right, we can see pretty good changes. This is a systematic review and meta-analysis that came out in BMJ. This is Dr. Hughes over in London who's actually our post-doc. And they looked at all the BF are studies that were for clinical papers. So clinical interventions not healthy, but they had to have an injury. And what they found was that if you looked at those, they compare low-low to load would be FR, that you had about a 70% chance of your patient and getting more street gains if you just simply added that tourniquet to it. So it's pretty easy to do, just take those same exercises and put a tourniquet on. And this is really what, what I'm excited about this and I've seen this personally in my trials as well as just in the clinic out of Germany, they took only the older individuals in study. So you had to be at least 55 years or older. And what they found was the biggest effect sizes we've seen so far. So massive effect sizes of 23, which means basically almost everyone that does this, they should see again in the older population. And so they're, they're quote down here, the application of external tourniquet seeps of facilitates significantly greater responses in mks or street compared with low level training alone. So it's not just a pro athletes Service Member thing. The elderly population is probably one of our main targets that I think we should be thinking about with this because they just respond extremely well. One of the early questions we had at our center is, does this increased pain though because HD is known in the orthopedic world that increasing or turn it gets increased pain post operatively. I gave a speech at a joint arthroplasty society years ago, the Ortho on our panel, his talk was decreasing tourniquet use in total knee surgery on my talk was increasing tourniquet use in rehabilitation. So it's kind of interesting way the world's going. So our surgeons at our, at our Bass said we really want to first look at does this increased pain like we know turning kids do and people post operatively. There had been no study that had ever address pain and blood flow restriction. And the other thing was no study had ever looked at does it increase clots postoperatively? There's a lot of studies and we felt pretty confident clots on a thing that has shown in healthy models and chronic training models and elderly models that we don't see increases in any of the clotting signs. But it hadn't been looked at in a surgical model. This was our first clinical trial on the DoD and across the board, the BF arguer had significantly less pain and improved Qu subscales. And we're already seeing that clinically that people would get done in this and just be like Man and my knee feels better, my elbow feels better after doing this. We also I don't have it here. We get a duplex ultrasound scans on individuals. They had to do this for at least a month from starting two weeks post-op, and we didn't see any signs of clotting postoperatively in any of these surgical patients. Now we're getting more and more clinical trials that are addressing pain. So this is rod white, these group is it asked Qatar? And they have two papers now that's looking at be FR with people with anterior knee pain. And what they've shown is when they retested them after doing BF arbors low load exercise. When they retested the squad is single leg squad or a step-down tests for 45 minutes or cutoff test-time. They had significantly less pain and people with anterior knee pain. And so what rotten them propose is look this this decreases pain, it looks like, and especially in a really kind of annoying group to work with these enter knee pain people where you're just trying to write how to get a quad strong when their knee hurts. I love it for this group. And what they propose is this might be a preconditioning process. So basically stack it where B FR is the first thing you do when your patient comes in, they're going to get this analgesia for probably up to at least an hour and then you can kind of work with them on to other things. We did a podcast one guys like, you know, that when they go after just range are doing manual work, they'd be off our first because people just seem to have analgesia. No one has looked at pain in the upper extremity or had so that our group we wanted to do kind of the same thing we did of the knee, do a study on risk fractures and these were elderly veterans to see, did we increase pain because we know there's all sorts of complex regional pain syndrome and such like that. And this was done with with Dr. Reed who's out at Mayo as well. And after due in four weeks of blood flow restriction on risk fractures, we we saw there was no deleterious effects on on X-ray. So we want to make sure to we weren't we weren't causing them not to heal up, but also we had a significantly as like 0.001 reduction in pain after that four weeks and they had all had increase self-reported function as well. So now we're getting more into larger risks. Upper extremity trials to see are we also increasing streak and hypertrophy clinically? So everyone wants to know a mechanism and we do too. So is there a mechanism behind why we're seeing reduced pain and individuals when they do blood flow restriction. And so we test look with this over in London and they've completed this trial, they have another one about to come out. And what they showed is that whenever you did 80% limb occlusion verse 60%, you had verse lifting heavy and this is in healthy individuals they had, they used a little pain pressure thing that causes pain. The 80% limb occlusion had significantly higher reduction in pained and lifting heavy, had a higher reduction in pain than the 60% and they also had a systemic effects. So that wasn't a lag also when they went to the upper trap, the BF are also had significantly less pain at that 80%. They also had more reduction of pain than lifting heavy 24 hours later so far seem to augment that pain response as well. And I'll talk in a minute why we think that is. And so we looked at is there's something there and what they found is there was an increase in this thing called beta endorphin into BF are in both groups, but it was the highest in the BF are 80% group. And if you don't know what beta endorphin is, it's one of your body's most powerful pain suppressors. It's an opioid that comes out in your pituitary gland. So if you hear pituitary, think, okay, well be FR, hits the pituitary and makes growth hormone come up. We think this is kind of a same mechanism that beta endorphin does. So when you do BY FR, we get this really large increase in lactate post while you're doing it. But then especially post because you're not that Annette lactate leave during rest periods. And then if you look at the GH curve, the growth hormone curve, it always kind of mimics a, it looks like a mirror of the lactate response. So you'll see this go up. Growth hormone actually will spike again if you get a good night's sleep typically. And so what we're seeing with this opioid beta endorphin is the same thing that as the lactate starts to increase, then, I'm sorry, lack takes the dotted line, that beta endorphin release will start to go up as well. And so what they said in this study is when they were doing these exercises, once you get that anaerobic threshold or you start to see this increased overproduction of lactate your body. Were always, we always say this, we're not in a cave man, we're in a caveman physiology. Still wear a hunter evolution physiology. We haven't evolved out of that. Your body didn't like to produce lactate using unless you were doing something really, really bad. Cavemen didn't lift weights for fun. So if they're running for their life or they're having to do something that's causing a ton of muscle activation. One of the first things your body does is let's just get through this event I want to live. So as our lactate to building up, the body's already set up. Ok, well here comes this opioid just live and we'll deal with it after the fact. So that's what's fascinating is we can now in rehab control lactate if you've done BY FR, that's one of the main things people say, oh my god, the socks because there's so much lactate within the muscle, but that's a positive and it looks like it increases its opioid release. So that's, that's a, that's a nice thing to see. And this is a large trial that we had over with the UK National Health Service looking at ACLs. And so when you did BF are about two weeks out till 12 weeks or lifted heavy two weeks out to 12 weeks. Post-op ACL. What we saw is the BF are and the lifting heavy group actually had almost the exact same changes in strength and muscle size. They were both significantly increase. They both did well, there was almost identical. But the BF armor at 12 weeks had significantly better. Why balanced scores? They had significantly better self-reported scores. Whoops, sorry, I just lost my forward button. And they also had significantly less knee pain after the 12 weeks and after whenever rechecking that after the treatments, they had significantly less swelling and they had significantly better range of motion throughout the entire rehab. So that's a beautiful kind of thing. You can start BY FR you don't **** the knee off. You can increase the range of motion improving less well and patients have less pain. And then you keep that muscle and then get them off the EFR and they can go on to the clinic or I mean onto the gem and start lifting heavy on their own. And so here's kind of a nice case. This is a NFL guy who had a bone tend to inbound ACL. He's months out from his from his surgery. He had that annoying anterior knee pain that you sometimes get with these patients where everything he did just ****** me off and he couldn't get his quad shrink back. He got cut by TV. I picked up by one of the teams we worked with and they started BY FR on him and this was government Week Two and then helmet Week four. So within a month he was able to get that quad back at a basically after this, he got off BY FR and just working with the street coaches and was able to continue on. He's still playing in the NFL at this point. So I think BY FR in the early stages is just great to avoid what heavy load could do to make an our pupils injuries sometimes worse. I want to kinda get here a geek out a little bit on what we're seeing from skeletal muscle when we're looking at blood flow restriction. So what is the deal with this where you see this much atrophy? This has a couple of weeks post-op ACL and you're already seen as massive muscled up on the right side of this leg. And so the, oops, the protein net protein balance equation is very, very simple. You take a bolus of protein, you're going to have muscle protein synthesis go for a few hours. And then it's going to shut off. And then it's going to start having muscle protein breakdown in your body kinda goes through this wave and it likes to keep it at net neutral. You're not lifting weights or anything. You're not really seen a change in that. So to atrophy, you either have less synthesis or you have more breakdown. It's that simple. It's in you. It's pretty, I'm sure it's pretty obvious to most of us, it's probably a combination of both, but here's what we do know. And this is from some of the top physiologists in the world been wall loop Van Loon, Mike already, Stu Phillips. These are called anabolic resistance trials, where they take individuals and they put them in a cast for two weeks with their knee flex so they can't use one limb. And what they do then as you're walking on crutches and after two weeks they measure your muscle protein synthesis rates in both limbs and compare it to what your muscle protein synthesis rates were like when you were walking. And what you typically see then is the limb that you're not able to use, your muscle protein synthesis drops by about 30%. The limb you're using wasn't changing at all. That teased out after that two weeks to you'd lost about 350 grams of muscle tissue. I hate the metric system. I have no idea what 350 grams are, but the heart weighs about 300 grams. So in these young healthy individuals, just by not being able to walk on their limb for two weeks and drop in muscle protein synthesis there are losing more than the size of their heart, primarily in there quad muscle. And then it typically teases out to a loss of Quad strength by about 30%. So that first two weeks, you really start to get this muscle dump that you see. And that's from a drop in muscle protein synthesis. And it's not just disuse. This is from Van moons lab again, just walking less. They walked a lot less, but they had individuals walk 90% less for one week, muscle protein synthesis dropped again by 30%. And there's big bad thing called myostatin, which tells your body don't put muscle on, make it start to break down. It went up three fold. So when your individuals are just kinda barely moving around, they're still having a decrease in muscle protein synthesis. So we in therapy needing muscle protein synthesis. Modality and lifting heavy can increase it. But if you can't lift heavy, lifting like with a tourniquet can. So this was a study that's over a decade old now, they did leg extensions where there without turning kits on, without Turn it gets no change in muscle protein synthesis with Turn It gets on at three hour time-point. Muscle proteins, synthetic rates went up 46%. So that's that easy. Come in, do this extinction exercise at a low load. If you got a tourniquet on, you can tell your patient your home exercise program needs to be get your protein in. Because I gave you and an increase in what's called the MTR C1 pathway even in elderly individuals. This is from Chris fries, a brilliant physiologists. He has a BF are NIH trial that we're part of with home as well. He looked at it in individuals that are 70 year old, men that were seven years old, that same exact trial Leg Extinctions and their muscle proteins, synthetic rates went up 56% at the three hour time point compared to low-level, which did nothing. There's another study out of Chris's lab that 24 hours later, the increase in protein synthesis was still up almost 60% into BF, our cohort. So that is one of the keys of blood flow restriction. That's super easy. If you can get within that 20 to 30% of a one rep max, get the tourniquet on just one exercise was able to augment muscle protein synthesis, which helps fight against the thing that is causing our patients to lose muscle. And that's that negative net protein balance equation because synthesis went down. There's also what if you can't do any exercise or almost nothing. So my patients coming in and all he can do is a quad set or they had a they had an Achilles repair and they can't do anything at all. They're stuck and it can be how you try and fight the loss of muscle there. And so these are called passive blood flow restriction applications. Or you might hear it called cell swelling or you might hear called RPC remote ischemic precondition. This is doing what for restriction in the absence of any exercise at all. And so this is one of the first ones that they took individuals, they did that same model two weeks in a cast. One group did nothing. One or just put a tourniquet on an inflated it and deflated it five rounds in the morning, in the afternoon. And if they did that, they preserved the loss of Quad strength by only, by, only lost 10% versus the control group which lost almost 30%. The hamstrings, they preserve the loss of strength as well significantly, and the calf muscle, they preserved it almost a 100%. So just get an attorney to get on and going through these inflations and deflations might have a protective effect of losing muscle mass. This was an ACL trial done in Japan where they get that same model, just put a tourniquet on an inflated it and deflated inflated it and deflated it. No exercise for two weeks after ACL. And what they found is they cut the loss of muscle and muscle loss in the quad as well as the thigh by over half, just by getting that hypoxic effect. And so people are trying to figure out, okay, what's the mechanism here? And so this is again out of, I think it's van loons lab or paradigm I things covenant over in Europe. But what they looked at is OK, what if you do passive BY FR and then you do low load be FR, Baidu load without BY FR. What are we going to see from muscle protein synthesis? And this is a great lab. Muscle biopsies. So really a good way to look at this. What they found was compared to load, load. Load would be FR, increased muscle protein synthesis. They confirmed what we already know. Yup, it's going to be what drives muscle protein synthesis. But the passive application didn't increase muscle protein synthesis compared to resting. So if there's a protective effect, it's not because we're increasing muscle protein synthesis more than likely. And so, and then loons conclusion was, if you want to stimulate muscle protein synthesis with BF, are, you have to combine it with doing this exercise. It is 20 to 30% of a one rep max. Where are we see in this preservation of muscle? It's probably then this side, the break downside that maybe were slow ended there. And this comes from what's called remote ischemic preconditioning. Google Scholar this and you'll get like ten papers a day. There's a ton of work in the medical world that if you put Turn it gets on the upper arm or the lower or the upper thigh. It has a protective effect. The most of the studies show that it protects people after they have heart surgeries or heart attacks, but it also protects the liver, the lungs, intestines, kidneys. There's massive stroke trials going on in Japan and Europe showing that there is some protective effect after stroke. And also there's a protective effect skeletal muscle tissue. So there's a lot of debate of what the pathway is here. But just show you kind of some of the work that we have with this. This is our guide, Dr. Patterson in London again. He had individuals do a 100, jumps off a box and then jump up again and then lands. So just destroying their quads. And then when they got done, they laid down and put the turn IT gets on it a 100% occlusion for three rounds at five minutes on, five minutes off, where they did a sham of that at 20 millimeters of mercury. And what they found is when they measured CK levels 24 in 48 hours later. So creatine kinase, a direct marker, muscle damage. If they put the turn kids on, we weren't seeing markers of muscle damage significantly elevated compared to the control group. It when they RE measured their strength, if they put the tourniquet on after destroying their muscle, they actually buy 72 hours later had completely restored their strength where the control group was still way down. This is an application we, we do a ton in the pro world right now, post games to try and stop muscle breakdown in these individuals. So there's some groups that have been looking at what are, what are the reasons of this? And so this is a couple of months old paper in what they looked at was OK, let's, uh, mobilizing individuals again for two weeks, put them on crutches. Control group does nothing to BF our group we're going to put on basically they went to fall. They didn't use LLP, but they went to beta much full occlusion, five minutes on, five minutes off. And again, a good study muscle biopsies at baseline day 11 week and two weeks out as well as an MRI. If you put the tourniquet on, it didn't reach significance, but it definitely looks like an trended that way for sometimes he's MR studies are really hard to pick up what's going on in a 100% with the muscle. But it looked like a help the quad, it reached significance on the hamstring. But you really, when you get these studies now biopsies, you go straight to that and it's significantly attenuated the loss of muscle over two weeks. If you put the tourniquet on in the vastus lateralis biopsy compared to the control group or another lose an almost 15% Muscle that's a lot of loss in two weeks. And so what they found was BF are slowed down the catabolic pathway. And so if you look at this, the one that was signifigant was muscle ring finger, one mirth one. If you don't know mirth one mirth one. As soon as you stop using a muscle around day two to two weeks out, mirth one starts to go up and it tells your body breakdown, breakdown, breakdown muscle in this area that it's not being used and they really attenuated down RF1. And so that's really impressive. If we have a modality that we can say we can do this to increase indoor, which is muscle protein synthesis. Or we can do this early and we can slow down mirth, one. That's where we're getting really kinda ninja our physiology in rehabilitation. And kind of the most interesting application, this is out of Brazil where they took comatose patients and just put the turn IT gets on, rotated around the arms and the legs. And they did passive range of motion and they were basically able to show that bf our overtime and all these individuals consistently reduce the loss of muscle. In this ICU study, Stevens group actually just finished one in Europe. They didn't get very good numbers, but they didn't reach significance, so the jury will still be out, but that's an interesting application. I want to veer away from muscle and just kind of touch base on some of the stuff we're looking at with bone as well as tendon here. I talked about this thing VEGF and hit F1 a whenever you put a tourniquet on and your limb goes from a norm oxic state to a low oxygen state. Hypoxia inducible factors, the Nobel Prize guys gene will come out primarily out of the bone and it tells vascular growth factor upregulate, VEGF creates capillary beds, but that angiogenesis when VEGF also creates osteogenesis. And so there's several other mechanisms on bone. But VEGF is probably the main target that we're really interested in. So this paper is about to come out. Finally, it's a ACL trial done in the largest healthcare system in Houston. Message method is health care system and I can't tease to measure results, but I can teach this because it's been presented and a OSS and I'm actually put this out as a press release academy meeting a couple years ago that when you did blood flow restriction from two weeks out to 12 weeks out, compared to the control, the control group lost about 11% of their muscle, of their bone stock down around their knee. But the BF, our cohort at 12 weeks had lost less than 3%, which is super, super fascinating that after ACL for wine, I don't think most of us really knew that, that your body starts to just go osteo peanut basically. And we're wondering Is that why maybe graph times take so long to heal. Bf are preserved that bone loss and we also preserved a lot of other things and maybe even got back faster, returned to play. Which again, I can't teach too much, but this is really fascinating. And so my majority of my big trials through the DOD are funded in looking at bone have a 4.7 going down our femur fracture trial with 14. Charleston and drum country, it's the largest BF are traveling the world. So we're really interested in the DOD, not only what we can do for, for muscle, but also can we help with bumps. Tendon is another area that just hasn't been looked at enough and we've got quite a few tendon trials as well. But this is the first one that came out and this one cause some problems. So what the problem was with this one? They did 80% of a one rep max or 20% of one rep max would be FR. And looked at changes on the Achilles tendon. And what they hypothesize was this big increase in lactate. Lactate increases collagen synthesis and that increase in college and census as you get from EFR, would be able to increase Changes in the tendon. And what they found was it didn't in the BF Arbour, the lifting heavy group did. So this created this, you know, some of my colleagues presented this at conferences as well. We gotta weightlifting problem here where BF ours like steroids, they're gonna get big muscles, but they're not going to help the tendon. They're going to be pop and tendons left and right, which we've never seen happen, never been documented that we need to do millions of these applications now. And there are some problems with this study. For one, in the lifting heavy group, they increased their one rep max every four weeks. This was a 12-week trial. The BF, our group, they never increase their one rep max for some reason. So after four weeks, if you're doing BY FR you're, you've gotten stronger. So if you didn't change it at 20% is probably closer to 10% at the eighth week if you haven't checked whenever Imax Again, that 20% might be less than 5%. So for some reason not increasing the 1RM and the BF, our group was just, was just hard to understand. And then they use these narrow cuffs and low pressures, which they just don't work. They don't they don't work for be FR. And so if they're hypothesizing lactate was what they were getting, what they used, probably going to help with that. And so just to highlight this, this is a pump up model here the things gotta be strong. They, they show on their site. If you pump it to 500 millimeters or mercury over here, it never occludes the artery and they claim that this makes it safer. And I claim that it's not doing GFR, it's doing nothing at all. A narrow cuff like this. It takes a ton of pressure to get down and close off the arteries. And so here's a paper that came out that looked at that. So they use the wide surgical cuffs that we like to years compare to that beast drawn these kinda pump up things that you see. And what they showed is the wide surgical cash for rate of perceived exertion. It was significantly higher. The low load would be FR or just low load. Rpe did not change at all. That tells you something right off the bat. If you ever don't be FR you know, it, it, it is way harder than just low load exercise. And so lactate again is one of our easiest markers to see if they've gotten fast-twitch metabolism. Low load did not increase lactate at all. The narrow elastic cuff did not increase lactate it all. They basically did the same thing, just like Washington's paper showed early on. But there was a large change whenever they use these, these the surgical tourniquet that we use. So that tendon study probably never got any lactate built up. So luckily, there's another one that just came out recently out of Germany. They did BY FR for three times a week, for 14 weeks, they use the same systems that we use, and they increased 11 RAMs every two weeks in both groups. The lift and heavy, as well as the BF arguer. And what they showed after that 12 weeks as tendon stiffness significantly changed with the lifting heavy grew and with the BF arguer and tinned and cross sectional area significantly changed with the heavy group. The BF are groups, so they did see positive tendon adaptations here. What Chris Center, what they hypothesize was not unrelated, the collagen synthesis, but whenever you go into hypoxia, the hypoxia and millieu increases tendon stem cells. And there's multiple papers that show that if you do decrease oxygen levels at which you see proliferation of the Tennessee. And so that's sort of hypothesis. There was more tenant tendon cells, so you get more college and synthesis. And that's why we saw positive adaptations. The only ones so far that's looked at tendon in an injured population was this one with chronic patellar tendon op with these. They did three times a week for three weeks here. And what they showed is in three weeks, they, they reduced the tendon pain by 50%, which is actually a pretty quick reduction. You'd have one deals or tendon off of these. The biggest thing you know about these is they are just a pain and they take forever. That's a pretty rapid reduction in pain. And the neovascularization reduced in three weeks by about 31%. We don't know if neovascularization is the cause of ten and apathy or if it even matters. But most people would tend an apathy habit. And as that resolves, most people's outcomes get better. And that's, that's faster than what you see. It typically takes about 12 weeks to get to those levels over the reduction. So this might be a way to kinda go at our tendon up at these faster. The nice thing about this is that 3D weeks, even though they're lifting light and we're getting these nice changes on the tendon. You're increasing muscle strength and size. Which so you're getting this kind of true for whenever you are doing it. Get getting close on time here. So I want to wrap it up on the vascular system. And this is real fascinating stuff that we're starting to see. This is a real problem and the population right here, what we call the oxidative stress stout individuals. These are obese individuals. Cancer, cardiovascular disease, diabetes, Parkinson's. A lot of these co-morbid type of individuals have really high oxidative stress. They have too much free radicals and their vascular systems are just really poor. And the problem with lifting heavy is it increases oxidative stress, it increases free radical production. And so even when you look at elderly lifting heavy papers, it might help with muscle, but lots of times it's making their vascular system worse. This is out of the American Journal hypertension. Elderly women, when they lifted at high intensity, it increased their arterial stiffness, it made it worse. And that was from a larger trial where they looked at men and saw the same thing. So you might be helping grandma Smiths with some muscle, but you could be making their vascular system worse. And if it's someone who has one of these oxidative stress diseases, you could be making them really, really worse. And so what we're consistently you are seeing is that when you get blood flow restriction, there's an attenuation of this oxidative stress. And so this is again from our partner, Jamie burrs lab. They did a biopsy on individuals. These are young, healthy. They did either lifting heavy or blood flow restriction. They biopsy post, and what they found was compared to baseline. Efr significantly attenuated the oxidative stress, the free radical release. And so Jamie's hypothesis was the lack of oxygen available even during the rest periods slowed down the electron transport chain and that's why we had less oxidative stress. There's a, there's another paper out there that showed a much larger reduction and oxidative stress. But I think it could be something that we just recently found out that when you do BY FR, This is an acute study. So one bout but it will be FR verse low load exercise. This increase in what's called the ace two receptor significantly goes up big time. And the increase in the stem cells within the vascular, vascular area significantly goes up as well. This was huge increases. This one best of the best this year for their Journal of Applied Physiology paper. And why this is important is this. You gotta understand the renin angiotensin pathway. Angiotensin gets converted by angiotensin converting enzyme ACE. Everyone's heard of ACE inhibitors trying to block this. Angiotensin turns to angiotensin two and that increases free radical production. So that pathway, when it runs, it makes increase in oxidative stress. X2 will convert angiotensin two to angiotensin 17 and it decreases oxidative stress. So whenever you make more AS2, you're helping with people's vascular systems. You're decreasing the oxidative stress. If you've heard of ace two, this is what COBIT attacks. That's why people with Cove ID we're seeing and they were having strokes and they were having clots, their vascular system an ace Jews also everywhere it's in your intestines into your lungs. Whenever a stews gone, all of a sudden this other pathway runs unchecked. You get tons of free radical production. The endothelium starts to fall apart. You get bleeding and you start to see what all of these clots and as you get older, ace two is reduced with aging. So us being able to upregulate ace two might be just extremely, extremely powerful. And so we just finished a study at Baylor University looking at Parkinson's patients who were oxidative stressed individuals. And they really show their vascular signs openly. They have what's called the purple Hands Syndrome because they're vascularity. Uh, so for most of these patients are, a lot of them die of cardiovascular disease. So they did lifting heavy, which is kind of the trend and his Parkinson's patients group. But again, we say that could make their vascular system worse. Or lifting light with blood flow restriction, we use 60% occlusion three days a week for just one month. What we found was really fascinating. Just consulted Dr. Bain. She's the one who did this. The homeless system levels, which are a direct marker of increased risk of cardiac events, went down into lifting heavy group, but they went down significantly more in the blood flow machine group here. This is an interesting that they were that highly elevated. And Hamas just the levels at baseline, we increased angiogenesis in the right leg and the left leg only in the fiber. And the real kind of target here, this is looking at endothelial function. Did their vessels get more compliant in better or did they get worse? You want to see this marker go up their vessels in the lifting heavy group after a month got worse, guts differ. The blood flow restriction group, they got significantly better and more compliant, which is huge in this population. So the conclusions here where the vascular health was really bad and these individuals, but when needed blood flow restriction, I'd put out there they did increase strength and hypertrophy. They did better on their functional testing than the lifting heavy group. And we really saw an improvement in India, the endothelial function, which could beg the question, are these types of things that we can do then we have these kind of patients just come in for one month, once a year for a vascular checkup, not just for the streak and hypertrophy effects we can get from it. And that's what's exciting with blood flow restriction now is we're not just see an orthopedic muscle patients going into these other groups. This is a huge trial we have going on with, with Germany where we're looking at diabetes and if you look at our primary aim, it isn't muscle. It's can we control insulin levels with blood flow restriction, which could be huge, I think for physical therapy, if we're able to start to come at things where this real scientific approach, we're trying to really put our money where our mouth is. Again, Kevin said 400 trials, I'm 40, I think 42 trials right now, but we have a lot of really high powered trials at some of the leaders around the world looking at this thinking. And that's my email. If anyone wants to reach out, feel free. There was a lot of talking with no water almost passed out. Johnny, That was fascinating. I feel like I need to take a nap. Now. If you want, you can unshare your screen and we can see you better. So I'm Stacy Larkin. I just want to thank you for attending or not attending but presenting. A lot of times Research kinda gets overwhelming and I can't believe how much research you presented to us in a very accessible manner. So thank you. It actually, you know, I never really dive deep into the physiology, but now it's like I, if, if I were younger, I would say, yeah, I want to research that's, this is fascinating to see the impacts that you're saying and, and have such clear objective data. Yeah, I think understanding physiology better is really empowered for physical therapy. And I was a bottom of my class kind of student, but I, in a military way, our main scientists or at our base. It's called them the history of Surgical Research. And just been around somebody's brewing physiologists teach me these things. It was like, oh my god, this is kinda opened my eyes. Everything we started doing, we started thinking about what am I doing to manipulate physiology here. Yeah, that's fantastic and I'm very excited and I'm going to start following this because the impact on circulation and is is really eye opening. So I hope I hope something comes event. Yeah, thanks. Yeah, we have a website once recovery science, where we have podcasts with a bunch of these researchers that I talked about usually go over, we just went over a couple of new, really big papers coming out of that lab in Houston. So yeah, if you, if you really love, hear my voice. Go there. We have a bunch of blogs to try and get this information out to everybody, right? Yaml will promote that on your website to go. I think for me it's definitely like Stacy said, the physiology retreat, the motion disorders and mood disorders and all the things that are Practice access. But when we think about it, we didn't have to go back to that basic building block and how those building blocks come together. And yeah, it's just a nice lately seeds that are a nice refresher on physiology. You know, hey, I'm trying to get my therapist to make those patients are heavier, harder in the geriatric world. But it's like, well, wait a minute. Yeah, we have those ports regulation, we have to make sure they get the protein. And so I did appreciate that is a nice reflection upon on the physiology. And then how can we incorporate some of that blood flow restriction into our geriatric populations? We're trying to get to the point where we can say, you know, I'm treating his patients with this to heal their bone or to improve their vascularity. And we haven't really had that in physical therapy where we're like we're doing this, they heal something. Or I can control muscle protein synthesis. So we're really hoping that this can play with the insurance groups. And we can start getting a code. Mike, my femur charles 250 subjects, you know, and if that one comes out positive, you know, then we can really start going to medicare and saying, okay, we need some stuff. How expensive are the costs? Rs is pretty pricey. It's the, it is not mine. Once we use it, it's from this company called Delphi. They're the biggest tourniquet patent holder and researcher in the world are in Canada, that those are like 4900 bucks. But that includes the system, the Doppler, the cuffs, kind of everything. So it's pricey and I think for me, if I had a clinic, I would if I was starting out now that and obviously I'm biased, I would I would have a unit because I don't know how I treat a lot of my patients. Now after doing this for over a decade. And nobody think good is the majority of orthopedic surgeons are really on board with this. I speak more in orthopedic conferences and I do rehab conferences. Most of our large trials are, are run by the orthopedic side of the house. And so, you know, it's pretty easy to go tell the surgeons, hey, we're doing this blood flow restriction thing, would show him our website. Can you send me some of your post-op patients? You know, some people don't like performers have showed just, you know, just large, large increase of those patients. I think a lot of people want these postsurgical patients. So if you get four extra just because of the surgeon knows you're doing it. And I would say go to the surgeon and say tell them, give me your worst ACL patient. Not worse if they're a jerk, but just as struggling. Because they just want those people to get better. They're not worried about post-op or whatever. And those people I love them because they're usually the ones that just take off like a rocket like that NFL guy that we saw and those people go back, they tell a surgeon omega2, this thing to me and my muscle, I never felt that forever and actually notice certain like Loves You. And this delphi system we use, it's on workers comp, every pro league in the country. So any pro athlete you see that has a limb injury, they're more than likely get incent these units to the team. So it's also the surgeons know because most of the big leaders in the surgical world or the team docs as well. Brown has a question. First of all, excellent presentation. Thank you. Let me get my my video up. I'm still in my car. They're going thanks. Hey, yeah, it's one of those days. Really loved it. You know, I just think like guy, we really don't think a lot is PT's as much as we should, I think and myself included about the true exercise prescription that we are doing. Physiologic responses to that. And so that was to me, awesome. I'm just wondering how the best way for us to determine the the crucial occlusive pressure. Well, okay. Yeah. But what's the best way to do that? In a clinic? Yeah. Well, the best way is the Delphi system right now. That's a validated, they use it in the surgical world. It okay. It you basically push a button and in my daggers at key, it'll, it'll do it for you. And here's the problem. You, if you want to know true yellow P, you have to capture all the arteries and you're going after these big arteries that are down by the bone. So what that does is it actually circumferentially measures and once the the arterial wave sign is gone, it's like OK, there's no more oxygen there. The next best is to use a handheld doppler. The problem with a handheld Doppler is your only catching one superficial ordered. So you're probably not really get ensure LLP, but it's better than not doing it at all. The other problem though, is there's a learning curve and that's been shown in the literature with handheld doppler because it only takes a little bit of pressure from that Doppler. And also do you think the arteries is has gone occluded when it's actually you just want a little bit of pressure. It's easy to fall off on it. We used handheld doppler as before Delphi had come up with these years ago. It was, it was some wacky numbers my interns or some of my systems we get when they were doing it. But that's the next best way. And after that there's really not. And a great way to just sort of guess at that point and the guy you're guessing. And so the problem is again, you could have too much pressure, which you don't want to write. The other problem is you could have not enough pressure. There was a o a trial where they just use an arbitrary pressure and they found that it got women with OUA, their thighs stronger and bigger. And then they did in men with the way they use that same pressure, which was way too low for men. And they showed that they didn't get bigger and stronger. Okay. Well, it looks I'd be up our works for women but not for me and is like, oh, he midpoint here, you didn't give them enough occlusion. If you're we're going after like tip of the spear, we're trying to get a code. You know, if you're bringing patients and we're just kind of guessing, it kinda goes against all of our clinical trial stuff, but it's all about money. And lots of times was it sounds like it's critical. You gotta know if you're gonna do it. If you really want to do this and you kinda know it. It's I, I think so and it covers you from a liability standpoint and that's why I was they could tell, yeah. Yeah, here's a study where they use these pump up be things in Europe compared to they use the Delphi. The Delphi is on a microprocessor. So turn it gets where class to FEA devices, which means they used to be high risk. I came up with the microprocessor which controls the pressure. So it makes sure the pressure is exactly what it is. The entire time the FDA went to class one inmate, definite targets were basically like a toothbrush, super, super safe when they microprocessor. Now, these pump up ones, they don't have that their blood pressure cuffs but you're not supposed to have a blood pressure cuff on for like ten minutes. Right. And when they put the sensors under these pump up one's compared to that Delphi, the Delphi, the pressure it showed you was the pressure that they were measuring the pop up. This figment Omri was here but the pressure was like all over. Okay, that's a liability issue because that's a published paper now. And if a patient comes back, the number one problem would turn it gets, we just had a huge retrospective thing. They looked at it from the wars is nerve damage. You'll take out a nerve. And so if you take out a nerve, that's because this pressure gradient squeezed onto nerve and D myelinated it and it, it squeezes the fat off. There's there's I when he's pumping devices, it's already they have an FDA adverse event from a patient that has a nerve issue that's been listed there and the FDA's really slow to react. But from a liability standpoint, you're screwed. Because you came, you could say I only get 200 are gonna be like, well, this paper says you don't know. It could have been four on because it shows a little boy. So so just because there shouldn't be where $4,900 is nothing Belgium averting lawsuit. Yeah. Yeah. You know, but but it's pricey. That's for sure. Yeah. Alright. Thank you so much. That's great. Thanks. Janani, I was I was fortunate to to be in attendance when you presented in February at Delaware. And the unfortunately with the people here can't do is experienced the unit summing, Johnny brought.
Morning sessions of APTA DE 2020 Annual Meeting
From Stacie Larkin November 09, 2020
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