Okay so I just wanted to with this lecture really for you know I know that there's probably a wide range of experiences with ultrasound. Probably some more recent graduates have had probably a little bit more ultrasound exposure compared to you know those who might be a little bit further out from training. So I just kind of wanted to go through like what are we using it for right now? What might we be using it for in the future? For anyone who's kind of interested in incorporating it more into their practice. And we should have some time at the end too if there's anyone else on the call who has you know a lot of ultrasound experience we can have you know some discussion at the end as well. So just a little bit about me. I grew up on Long Island which I that's obviously not Long Island in that picture. But I went to college at the University of Colorado at Boulder which is a beautiful place. I had a great time there and then I went on to med school at the NYIT College of Osteopathic Medicine back on Long Island close to where I grew up. And for my residency I stayed on Long Island at Northwell Health and spent a good amount of time at Cohen's Children's Hospital. And then for a fellowship I was at Children's Hospital Colorado and now I'm back on the East Coast New Jersey at Hackensack. So for today like I said we're going to go through some of the pros and cons of using ultrasound in a pediatric rehab practice. Some of the current uses and then future uses. So in general just some benefits of ultrasound in pediatrics. So it's a painless exam. It's pretty portable. Even the machine that I use which is like a Sonosite kind of like a little bit bigger machine but you know you can still roll it all around the hospital. And now there are a number of different ultra portable options that like you know connect via Bluetooth to your phone or your iPad so you can kind of just be holding a very portable probe in your pocket and use it anytime you need it. Ultrasound can require less or even no sedation compared to some other imaging modalities. Bless you. Although this does depend on the procedure and the patient tolerance because for instance like if I'm doing Botox for a torticollis patient or like a salivary gland injection kind of in more sensitive areas around the neck I really need the patient to sit very very still and allow me to like do the ultrasound and the injection. So there definitely are times where we are sedating patients while we're using the ultrasound. Sometimes it could be faster than other imaging modalities. You know a lot of places have you know could have longer wait times to get something like an MRI. So if you have your own ultrasound in the office it's a little bit maybe a little bit faster to get some preliminary imaging with that. It's really great for targeting non-muscle structures as I mentioned before. I do salivary gland injections so really easy to visualize those with the ultrasound. You don't necessarily need the patient to be positioned in an anatomic position which as anyone in PEDS rehab knows we have lots of patients who for whatever for many different reasons either can't be positioned anatomically or they have contractures and other other things going on that make their anatomy a little bit more difficult to assess. You can use the Doppler setting to avoid vascular structures which I definitely use for the salivary gland injections and some other injections and can also decrease the time that the needle is inserted and have a decreased need for needle adjustments because you're kind of visualizing exactly where you need to go. You can also visualize the injectate once you you know push the plunger and another benefit that I find is that you know kids sometimes are a little nervous when they're coming in for a procedure but like they usually find the ultrasound pretty cool so like kind of showing them their their muscles and and all these different things can kind of relieve some anxiety as like almost like distraction. So limitations of ultrasound it can add extra time to do procedures it depends obviously on your skill level. I'm definitely still learning and getting you know trying to get better using ultrasound so in comparison doing some procedures without ultrasound still will take me less time than doing it with. It does require the child to sit still especially if you're doing a procedure it does require two hands whereas you know sometimes we're doing Botox and kind of have one hand bracing the child and the other hand doing the injection so with this you know you kind of need some extra help to make sure the child stays still. It also depends on the equipment that you have so different ultrasound machines can have different levels of resolution then that can kind of impact your ability ability to differentiate structures and just have a clearer view of what you're looking at. Cost is obviously an option especially versus methods like just palpation, ECG and EMG. The cost of an ultrasound is much more than that and like I said before it's user dependent depends on your level of experience with the ultrasound. So for guidance for procedures there's many different options that we have and procedures I'm mainly talking about like Botox, alcohol phenol blocks because I think that's what most of us in Pewds Rehab are doing. So the main methods that we have are you know just by surface anatomy, also using our palpatory skills to confirm the surface anatomy, and then using ultrasound to confirm the surface anatomy. We also have our EMG slash e-stim machine and then ultrasound are kind of the main ways that I've been seeing being used. Our goals for using guidance is to minimize procedure risk, optimize outcomes and efficacy, reduce dose like the effective dose if possible, and minimize adverse events. So I just I'm not going to go through all the literature on this but I just wanted to highlight a few studies. So this article on muscle and nerve they these two electromyographers there was a resident and attending they placed EMG needles in fresh frozen cadaver limbs both with and without ultrasound guidance and they found that the non-guided needle placement was significantly less accurate than the ultrasound guided placement particularly with less experienced electromyographers and they found that the overall accuracy for using anatomic guidance was 39 percent whereas the accuracy for ultrasound guided was 96 percent. This was a systemic systematic review where they looked at injection guiding techniques mainly with Botox for treatment of spasticity and dystonia. They found that the rate of correct needle placement using the manual needle placement alone was low even in the procedures performed by experienced clinicians and so ultimately they recommended some kind of guidance be used for Botox in both adults and children whether that was EMG, e-stem or ultrasound. They didn't particularly differentiate between those. In this systematic review they looked at the outcomes after Botox with different methods of guidance. So they said that there's level one evidence that EMG, e-stem and ultrasound are superior to manual needle placement alone and also noted that which again is as I at least in which again is as I at least in where I trained most of what we're doing already we're really trying to do like end plate targeted injections which were found superior to multi-site quadrant injections and that high volume injections were superior to low volume injections. And in this study they were looking at it was it was for adults but they were looking at patients with spastic aquinas so they're mainly injecting into the gastrocnemius and they wanted to compare the manual needle placement, e-stem and ultrasound. So they found at four weeks patients who had the ultrasound guided injections had a greater reduction in their Ashworth score for spasticity than in patients injected with the manual needle placement and the ultrasound group also had a greater increase in the range of motion compared with e-stem and manual injection. They of note they did not find any difference in the TARDU score which is another measure for spasticity. So now I want to move on to kind of more neuromuscular and electrodiagnostic uses. So some benefits in this area is that we can provide additional information for patients who may not be able to meaningfully participate in electrodiagnostic testing or who many as as I'm sure anyone who's done an EMG knows there's many patients especially in pediatrics that are not able to tolerate the full exam. So and if you perform the ultrasound prior to nerve conduction and EMG you may need to sample fewer nerves and muscles to reach a diagnosis. If we can get a lot of good information from the ultrasound then that can either mean that we don't have to sample as much or we can be more targeted in which muscles we choose and I'll go into a little bit more of that in the next few slides. And then there's also increased potential of a successful electrodiagnostic study if you have those ultrasound findings and also you can use it for guidance of the EMG needle if the anatomy is difficult. Limitations is that overall the research in this area is limited and there only recently are some reference values that have been made available but they still need more research. So there was and with reference values I'm mostly talking about like cross-sectional areas of like different peripheral nerves some parameters around muscles things like that but so that you'd be able to kind of say okay in this five-year-old patient you know the cross-sectional area of this nerve is supposed to be this amount versus a 10-year-old it might be very different. And there's still a lot that we need to learn about these sort of like normative values in pediatric patients so the reference values are great that we have something now but they're not perfect so it's just something to keep in mind. So it's also important to remember that the same way that the electrodiagnostic studies are an extension of our physical exam that if you are going to use neuromuscular ultrasound you should be treating that as kind of like an extension of your electrodiagnostic study. It's not necessarily a replacement there's still a lot of good information that an important information that the electrodiagnostic studies provide. That said ultrasound can confirm the localization of a nerve entrapment in mononeuropathies and give insight into why there was an entrapment. So for example you know you might do your electrodiagnostic study and find that oh there's you know an ulnar neuropathy that you suspect is you know somewhere around the elbow but we know that there's like multiple possible entrapment sites just distal to the elbow so using the ultrasound can help you really localize exactly where that entrapment is and you can see like is it because of scar tissue is it because of you know a cyst or you know whatever it is like it might give you some information as to why it's why it's happening. Ultrasound can also confirm a demyelinating polyneuropathy when electrodiagnostic studies are inconclusive and as I kind of mentioned before that's usually looking at the cross-sectional areas of the nerves themselves both like proximally and distally to try to see is it is there like a uniform enlargement of the nerves that would point you towards you know like more like an inherited neuropathy or like different etiologies that you can kind of see. Ultrasound is also more sensitive at detecting fasciculations which is which I found really interesting as compared to needle EMG. So if you have a patient where, you know, you're suspecting some kind of motor neuron disease and, you know, especially, you know, kids that, you know, now with newborn screening, we're catching most of the SMA babies, but I'm sure we've all had, you know, kind of some of these rare cases where they doesn't show up on the newborn screening for whatever reason. And the baby is still have, you know, the diagnosis is still in question, especially for a newborn, very small infant doing, technically doing the ultrasound is much easier than trying to vocalize with the EMG. So that's an option. You could also pretty quickly identify the pattern of muscle involvement and different myopathies versus MRI. We know MRI, you know, doing each body segment, you know, on the MRI takes a decent amount of time and some kids need to be sedated for those studies. So to be able to quickly scan an awake patient, you know, scan arms, legs, trunk, you know, you might be able to do that a lot faster than an MRI would take. So what are we looking for when we're doing all these scans, right? So especially for patients with neuromuscular disease, we are, this is like the most, what's the word? I guess like common scale that I've been seeing used is called the HECMET scale, somewhat subjective, but there's definitely some objective markers to differentiate some of the grades. But generally the more involved or affected a muscle is, the more echogenic it becomes. So it looks, you know, more gray, whitish essentially. So if you only have mild involvement, you would just have a little bit of increased echogenicity compared to normal. Which again can be subjective and, you know, depends on who's ever doing the ultrasound, their experience in looking at muscles. But also there are features on the ultrasound machine that you can use to better, more objectively, like grade the gray scale and everything as well. And I see that more like, especially in research that they're being much more objective about it. In moderately involved muscles, you'll see that the internal architecture of the muscle is starting to become obscured, but like especially here on the right, this right image with the four pictures in the grade two, it's like the top right box here, you can still see the underlying bone echo. Whereas in grade three on the bottom left, it's like, you can just barely see it, but it's really starting to be pretty obscured. And by grade four, it's like you've lost your internal architecture of the muscle, you've also lost the bone echo. So that's when you really know it's severe. There are different patterns of involvement in the ones in this like classic, like HECMAT scale four images on the top right. This is more like what you would call a uniform involvement. We're usually seeing this in like primary muscle diseases like Duchenne, whereas on the bottom left of the screen is an example of a patient who has a neurogenic pathology. And you can kind of see the difference where they sort of have like this patchy, streaky involvement. It's like the whole muscle is not necessarily obscured, but you still can use a lot of the principles of the HECMAT scale in grading this kind of patient as well. It's just that kind of pattern is more typical of a neurogenic condition, where the uniform is more typical of a primary muscle disease. And then just to like confuse you more, there could be like mixed patterns as well. So for myopathies, I kind of mentioned this before for newborns and infants, you don't need sedation to use the ultrasound. And you may also be able to detect myopathic muscle earlier on the ultrasound as compared to the MRI. So definitely something to consider for like consults in the NICU and things like that. Severe myopathic involvement. On the other hand, you can kind of hit this threshold where even if the myopathic involvement becomes even more severe, you won't see any more change on the ultrasound. So in those cases, it may be better evaluated with MRI. We talked about identifying fibrillations and fasciculations in real time. And also just the patterns of muscle involvement. So kind of quickly scanning different muscle groups, seeing which ones are involved and then correlating that with what we know about certain myopathies and which muscles they tend to involve versus others. So I just wanted to, the picture at the bottom here is kind of interesting. And this article in general is really interesting. So if anyone's like really interested in neuromuscular ultrasound, I would recommend taking a look through it because it points out a lot of disease specific patterns that you might see with neuromuscular ultrasound. So this was just one example I picked out in a collagen six muscular dystrophy that you can find this central cloud in the rectus femoris. So you can kind of see it on the left-hand side that like increased echogenicity. They call that the central cloud. And then you could also see it on the MRI. And that is, you know, may help you kind of with your differential in a certain type of myopathy maybe before the genetics are back and things like that to differentiate because they have, you know, these very kind of pathogenic mnemonic findings. So neuromuscular ultrasound is also being used to help in research of different neuromuscular diseases especially with new treatments coming out thankfully over the past, you know, five to 10 years. There have been a lot of effort looking to how do we objectively follow these patients both with natural history and also with seeing if they're having disease progression or improvement or whatever, like with all these different types of either gene therapies or other therapies that are coming out. So specifically with Duchenne, this article on the left from muscle and nerve, they were talking about using quantitative ultrasound to measure disease progression. And they found that they could still see disease progression even in boys that had functional improvements. So they were kind of investigating it more as being used as an outcome measure for young boys with DMD. In addition, you know, to the typical things we do like the North Star assessment and all of that. The article on the right was talking about FSHD and they were also finding that ultrasound may be a good like biomarker to use in research to establish, you know, like I said, like natural progression and response to disease modifying therapies. But in both of these areas, there's more research that needs to be done. I would say I've seen the most coming out and being used in like Duchenne, but there's definitely going on in other disease research as well. This article, they were looking at ultrasound patterns in CMT and hereditary neuropathy with pressure palsies. So it kind of went along with what we know about these diseases, that the nerves were larger in demyelinating diseases rather than axonal. Nerve involvement was symmetric. The CMT1 patients had larger nerves than other patients with other CMT types. And the patients with HNPP had enlargement at the entrapment sites, which is exactly what we would expect. So it's just kind of like a confirmation that we could potentially be using neuromuscular ultrasound in addition to our other investigation methods like electrodiagnosis to confirm these conditions. I think this is one of my last ones, the neurologic amyotrophy or Parsonage-Turner. Some of you might know it better as ultrasound can also be used here. Studies have identified that there's a correlation between these nerve constrictions on ultrasound and interoperative findings of nerve torsion. So over here on the right, the top picture is an ultrasound image and the arrow right there is pointing to this area of nerve constriction. And then you can kind of see this twisting in the actual interoperative image. That's this really classical finding in neurologic amyotrophy. The interesting thing about this is we're still not totally sure how these areas of nerve torsion like relate to the pathology of neurologic amyotrophy. But nonetheless, they're a good way to identify it. And then you can also use the ultrasound, as I said before, to using like the HECMAT scale to identify muscles that have been denervated. So in the left picture with the four images on it, what you can see on the top is like the unhighlighted image. And you can see some muscles have the nice, what we call like the starry night appearance, echo texture, whereas some of the other ones have become more, have increased echogenicity. So they would be like higher graded on that HECMAT scale, kind of identifying which nerves are being involved in neurologic amyotrophy based on which muscles are being denervated. So future uses of ultrasound. The main one I wanted to touch on is, especially because I find this a lot as I'm using the ultrasound more for Botox and alcohol blocks, is how can we use ultrasound in like our CP population who have spasticity and to help identify patients who maybe are really good candidates for injections versus ones that maybe are not gonna respond as well to injections. So the study on the left, they were looking just reliability and validity of the HECMAT scale and evaluating muscle changes with ultrasound and spasticity. So they've found, but I think a lot of us who use ultrasound will see that the spasticity can alter the muscle architecture. And you can see that with the ultrasound. Spastic muscles have increased echo intensity and may respond less favorably to Botox and the modified HECMAT scale had good reliability and validity in spastic muscles. And then the study on the right, they similarly looked at the muscle echo in response to Botox in patients with stroke. They found that all of the outcomes were significantly better in the patients who were graded two on that HECMAT scale than those graded three or four. So more severe after Botox. So I think we need more research on this, but it definitely starts, sometimes I'll be doing ultrasound, using ultrasound to inject a patient and they just look like they have a grade four HECMAT in the muscle that I'm about to inject. And you just wonder how many like functional, you know, sites where the Botox, like how many receptors are even there for the Botox to bind to, or are we just like injecting this into like fibrous fatty tissue and it's not really doing much for them. So I would love to, if anyone else has any other opinions on that, it's something I'm currently pretty curious about. And I think that's it. That's my cat, Momo. And if anyone has any questions or any other ultrasound things they want to talk about. Thank you so much, Dr. Rothman, for this amazing talk today. Just want to remind the audience that this is being recorded and will be available on the online learning platform before the end of the week for people to review. But thank you so much. Definitely came across with up-to-date information as well as how we can apply this in our individual practices within Peds Rehab. So thank you so much. No problem.

ultrasound

pediatric rehabilitation

needle placement

diagnostics

neuromuscular

spasticity treatments

cerebral palsy