Hello, everyone. Thank you so much for being here. I am Hanna Azizi. I have served as chair of Pediatric Rehab Community, and I'm very excited for today's session. It will be prosthetics and orthotics in pediatric rehab, which is usually a topic not that familiar to maybe most of us, and it's not our bread and butter topic usually. And our presenters for today, this is a schedule. The first topic will be It's Electric by Dr. Scott Wired. And the second one, it's What About The Shoes? And you see, even the topics are very exotic by Dr. Satlina. And after that, an announcement by Dr. Hartman, and that will be it for today. These are our presenters for today. And I'd like to first thank all of you for being here. It's a real dedication to our field, our pediatric rehab, and the community to attend these sessions after hours, and a greater dedication for those who prepare and present on this day today, Dr. Scott Wired and Dr. Satlina. And also, I'd like to thank our amazing team members, community team leaders, who attend meetings after hours every month, sometimes twice a month, to make this day a better day for all of us and to have other activities which are managed by community, pediatric rehab community. So Dr. Hartman is the Vice Chair of Pediatric Rehab Community. Dr. Emily Kevlehan, she's the Vice Chair of Education. And Dr. Becky Siegel, she's the Vice Chair of Communication. And Dr. Cassidy is Trainee Vice Chair. And this year, we have had great activities because of them. They have brought new energy and dedication to the field. And I'd like to also thank AAPM and our team members who have always been there for us and help us with everything we have needed. And at the end, I'd like to thank our elite pediatric rehab faculty who are here to support us today. And they always attend these sessions, even though they don't need it, but they are here for all of us. Thank you for being here. And with that, it was very short. I will leave that for Dr. Scott Wired. And for Dr., actually for Dr. Siegel. I turn. Thank you guys for coming. So Phoebe Scott Wired is a Rehabilitation Medicine Specialist at Rady Children's Hospital, San Diego, and an Assistant Professor at UC San Diego School of Medicine. She is double board certified in Pediatrics and Physical Medicine and Rehabilitation. Originally from Maine, Dr. Scott Wired completed her undergraduate degree in Behavioral Biology at Johns Hopkins University before attending medical school at Western University of Health Sciences here in Southern California. She completed a combined residency in Pediatrics and Physical Medicine and Rehabilitation at Cincinnati Children's Hospital Medical Center and University of Cincinnati. She served two years as a Peace Corps volunteer in Ecuador and is fluent in Spanish. Before coming to Rady Children, she served as the Medical Director of the Child Amputee Prosthetics Project Clinic at Shriners Hospital in Los Angeles for six years. She is also Vice President of the Association of Children's Prosthetics and Orthotics Clinics, the only professional organization for pediatric amputee care. She has served as a volunteer for Camp No Limits, Challenge Athletes Foundation, and Angel City Games. Welcome and thank you. Thank you so much, Becky. So I picked this topic because it's something that I feel like I wanted to learn more about and it was something that I had a lot of patients coming to me asking questions about. So as I'm sure you probably know, if you've watched, seen social media, been on the news at all, there's lots of new 3D printed products coming out that are direct to consumer marketed when it comes to myoelectric prostheses. And so a lot of times you'll have patients coming in saying, hey, can you get me that blank, blank arm? You know, I saw it on, you know, I want the Iron Man arm, et cetera. So that's kind of why I wanted to use this, this forum to kind of talk about this topic. And I'm excited. I hope that it also sparks some conversation and questions and discussion afterwards, because I would love to hear about other people's experience. And for those of you who remember the electric slide that's why I chose the topic, the, the actual name. So I am a paid consultant for Hanger Clinics, which should not, does not have any bearing on this lecture. They do not provide any of these devices. So these are my objectives and they were all sent out to you guys, but just to kind of review very quickly, I'm going to go over the very, very basics of upper limb myoelectric prostheses. And if anyone here was an electrical engineer in their former life, please don't judge me. I am not an engineer. I'm also going to talk about the different commercially available 3D printed myoelectric prostheses. There are kind of three major ones. And so we're going to go over kind of the pluses and minuses of each and talk about each one. So you'll be a little bit more familiar. And then also I'm going to talk about what little we do know about outcomes as far as the long-term use of these prostheses and are they functional? Are they something that patients continue to use? So first, just a few words on what is a myoelectric prosthesis. So for those of you who might not do a lot of amputee care, this, it might be reaching back into the, the, the distal realm to remember this basically. So it's a different prosthesis in that it doesn't require typically a harness, especially if you're talking about a below elbow level, it's internally powered. They're, they, most of them, and we'll talk a little bit about this later, use EMG surface electrodes. So they do require some evaluation ahead of time to make sure it's something the patient can actually move and use. So these EMG surface electrodes that are typically embedded within the socket, amplify this, pick up the movement, amplify it, then process a motor, which can move the hands, the wrist, or in an above elbow amputee, the elbow as well. And this has also, which we're not going to go into today, but targeted muscle renervation or TMR has given us lots of exciting new options as far as multiple sensors that can do all kinds of complex movements. The hands can be either a single motor or they can be multi-articulating to do different positions. It is heavy. If you think about it, it has a battery. It's got a motor. You've got all these extra parts and pieces compared to either a passive prosthesis or a body-powered prosthesis. It's going to be a lot heavier. So for something to keep in mind, if you have a patient who is a below elbow amputee, transradial, that is very short, it might actually be very difficult for them to suspend in a typical manner. And we'll talk about that more as we get into the 3D printed ones. It's much more expensive than your typical body-powered prosthesis can run between 10 to $20,000, depending on how extensive the prosthesis is for a below elbow amputee. But when you're talking about myoelectrics, you can add a zero. So it's closer to a hundred thousand dollars, especially with some of the newer kind of fancier multi-articulating hands. Also, more training is needed. Typically, these patients do need to work with an occupational therapist very closely to make sure they can be able to use the prosthesis in a way that's meaningful. So to jump right in. So the first arm that I want to talk about is the hero arm. And so the Iron Man arm, because there was like a couple of big things that they did where they had Tony Stark present these children with arms, etc. So this one is only for seven years and up. Of the ones I'm going to present today, this is actually the only one that has an L code that can be billed to insurance. It's not that it's not heavy. It weighs about 12 ounces, which is pretty light when it comes to a myoelectric prosthesis. It's for seven years and up. Supposedly they can, you can lift up to 30 pounds with it on though. I would argue that also depends on how well it's suspended. So it doesn't fall off when you use it. It's only marketed to below elbows. So anybody who's shorter than that would not be able to use this specific arm. The nice thing is these design covers are swappable. So if maybe you don't like Iron Man anymore and you want to try a different cover, you can have a different cover. There's up to six grips. You can see the big dot on the back of the hand there. That's the freeze mode. And I'll show you a little bit more about that in the video. It has a boa closure. For those that might not be familiar with a boa closure, it's probably in the last 10 or so years been used a lot more in prosthetics. And you can kind of see the little black dot, the black button on the top. So ski boots will often have these as well. So basically the socket itself is separate and there is a wire that runs through all the pieces. So as you twist the boa, it goes and it closes in. So that's nice for some of your patients who might have volume changes during the day. It'll still fit no matter what, because it's basically customized to the day of when you put it on. So as with most of the ones we're going to talk about today, this has, it's called the Sidekick. Get it? Like hero, sidekick. So they have an app that you can use to train to be able to use it. You get it on your phone. It's really easy, user friendly, et cetera. So they've kind of bypassed the whole occupational therapist piece. Just pay attention to that. You can add up to a five-year standard or premium warranty, which is nice if you're talking about kids that might be breaking things. The inner liner is washable, which is pretty nice to help with, prevent skin problems. It does require a prosthetist to fit or cast them. So typically they, Open Bionics has relationships with different prosthetists around the country who've agreed to get certified in how to make this arm. If you so desire, you can fly to Colorado to their special clinic and get fit there in a really short period of time. I believe it's cheaper. I've been told. I think they balance it out so the patients have less of a copay perhaps. I'm not sure. I actually personally know one of the prosthetists that works on the hero arm and she was not allowed to tell me how much it costs. I begged and begged and begged to explain to her what this lecture was for and she said, I officially can't tell you. So basically it depends on the insurance. I did scour the internet and find that it's upwards of three thousand dollars just to kind of give you an idea. So we're going to watch a video and I know the sound is a little bit light, but it's more of the watching piece. And I know videos don't always do well over Zoom. So if not, you can always look these up yourselves and watch them later. You get your bread out and you get your knife to put the butter on and I'm just gonna get this knife in the grasp position. So I'm gonna slide the knife onto the string where the fingers are so I get the best grip because that's where I feel the best grip is if you really want to get a hold of something. But I'm just gonna slide that on to string. You know, she kind of gets her arm stuck a little bit there. In there. So now it's in freeze mode and you can see she's also manually moving that wrist. So there is not a wrist motor that is in this. Functionally, I also can't help but point out that she is using her other arm extremely dexterously. So this is probably, I don't know this person, but I bet that she is very functional with both of the ends of her limbs without any prosthetic there. And I'm going to put cheese on my thumb. So that kind of shows you some of the different grips that they have. So it's flat but then you'll be able to get the cheese out easier. I'm going to use the grasp position and then I'm just going to kind of pick this cheese up. You can use your other hand or arm to help out if you want. And then you can just splat it on. Then I'm just going to grab the piece of bread to complete my sandwich. Put that on top. You can use your other arm to help. And there you have a cheese sandwich. So no comment on the health of having a cheese and butter sandwich. I'm not a person to judge that. So let me go back just briefly. Sorry, I won't make you watch that again. I can go up. Yes, I can. So anyway, so if we have questions about that one, you can let me know at the end. So that's the hero arm. So moving on. So this is a little bit different. So Limitless, everybody likes to use LIM or things in their names I find. So Limitless Solutions was actually started by a grad student at University of Central Florida. So this is a little bit different in that it's not a private company. And so the caveat with that is you can only get this arm through the clinical trial that they're doing because it's not FDA approved. So they don't have an L code, they don't work with insurance, but it doesn't cost anything because it's through the clinical trial. I could not find any information about their fitting process. So I apologize. I don't even know how they're fitting these patients. This also uses EMG sensors and there's multiple pre-programmed gestures that they can use with the hand. They also have developed a game for the prosthetic arm training. And as far as I know, this is not an app on your phone. It's something that you would do at their location. There's also interchangeable sleeve designs. I believe they're just magnet designs. So like you can decide what color you feel that day. They do fit people that are children that are risk to circulation all the way up to above elbow. The cost to them is between $400 and $1,000, but it's free through the clinical trial, which is only ages six to 17. They have recently opened up that to include adults. So over the age of 17 who are either first responders or veterans. So that does kind of limit what audience these ones are available for. And this is just an aside because I love adaptive technology. They are also working on EMG sensor based technology that could be used to either drive a power wheelchair or for like gaming types of things. So let's see a video of this one. 12 year old Sammy Atkinson's arm is part function, part personal fashion. I just take the color navy blue. Sammy was born with a condition that caused her arm to develop incompletely. Three years ago, she joined a trial being conducted by Limitless Solutions. The scientists specialize in developing advanced muscle sensing technology. It's not heavy anymore because I use all my muscles. The newest version of the bionic arm uses electromyography. When the muscles flex, they produce a voltage like a battery. And with the same stickers that you would use for having an EKG on your chest, we can put them on the bicep muscle. And then when that muscle is contracted, it will read that signal and send it to the computer chip that's in the hand. And that will tell the hand to do different gestures and routines. Next, these researchers want to know what changes are occurring in kids who were born without limbs but now have prosthetics that can pinch and lift. We're looking at seeing if there's any changes in the brain and the functionality. Sammy says in the past three years, she's been able to help with chores at home. I could fold laundry, I could fold shirts, I can fold anything. The researchers say the prosthetics empower children at a time during their social development when they may need validation most. Just always remember that you're special with a bionic limb to prove it. I'm Marty Salt reporting. So like I said, that one is only available to people who are in that study. So just kind of to know that that's the limitation of that one. Though the plus sign is that if they are accepted into the study, it's free to the patient. So let's move on to the next one. So the third one I wanted to talk about is true limb. Once again, it's got to have limb or some kind of from my unlimited tomorrow. So this one is colored. You can get the color to match your skin. They send you swatches. And there are a handful of patients who've chosen to get designs on top of the cover. So all of the covers that you're going to see today in this patient as well as in the video are skin colored, but that is they send you the swatches and then the patient gets to choose what color they want it or if they want some other kind of design involved. So there's a two-year warranty. This one also uses 3D scanning and printing. They actually send the patient an iPad or like a tablet in the mail and they use that to do a 3D scan with their own technology. And then from that, they'll work back and forth with a prosthetist that's part of the company. They actually send them in the mail like different check sockets they can try on. Supposedly the fingers can withstand 15 pounds of force, but like I said, it has the remote socket fitting. So that's using a prosthetist that's at a distance. It's made of nylon with acrylic and rubberized coverings. This one also has a BOA closure, which you can kind of see a little bit here on the volar surface, that little black knob. So as she turns that, you can actually see the wires in this BOA system. So she probably has a Velcro strap above her upper arm. So this one is a little bit more suspended, a little similar to a body power prosthesis. And then it does go for this below elbow child above her elbow. It is not waterproof. It's splash proof. The other ones didn't comment. So I'm assuming they're not waterproof at all. The timeline to fitting is about eight weeks. So two months, it's a pretty decent turnaround compared to your typical prosthetic myoelectric prosthesis. This one also similar to the hero arm only fits trans radial to wrist disarticulation. The cost is about $8,000. And this is when it's definitely direct to consumer. They do not work with insurance. There is no L code. They do offer discounts for people who need, like say a child grows and the hand is much smaller than their other side or something like that. They have like this 50% discount. So they know that they are marketing to children, which I appreciate a lot of companies don't. So this prosthesis is a little different. It actually doesn't work off of EMG sensors. It uses topographic sensors, so not necessarily electrical signals. So it's quite different. It has these 30 sensors that are embedded within the socket. This one also has an app where people would use that app to train how to use it. So kind of once again, they've kind of cut out the occupational therapist in this training process, which is why a lot of OTs that I spoke to in preparing for this lecture, really don't have a lot of experience with these because the children are not coming to COT to get trained to use them. So let's watch a video and see a little bit about this one. This one actually doesn't have any spoken words. So this is just showing some of the different grips that this particular prosthesis has. And then once again, this is called the true limb. And a lot of these you will also see at our conferences. So if you go to any of, definitely if you go to ACPOC, they'll be there. If you go to AAPMNR, I'm sure they'll be there. So they also know that they want us to have heard about their prostheses so that when patients come to us asking for them or asking for a referral that we'll provide that. I love it when people in videos use their prosthetic arm for fine motor activities when they have a dominant arm, but that's me. That's my pet peeve. And I believe this one also has a freeze mode with a button that's on the media arm. And apparently you can play Django with it, so there you go. And just looking at it, this one you can definitely see that it has like 3D printed componentry, right? Like it doesn't look as smooth as some of the kind of typical myoelectric arms that you may or may not have seen on your patients or in other videos. So let's talk a little bit about outcomes. So shock and surprise, there are no randomized controlled trials or outcome data on this new technology. We know, in general, that the earlier you have children exposed to prosthetic arms, this increases their acceptance. Typically we try and do it earlier than two years, that's kind of where the data seem to make a bigger jump. In my experience, there's no magic with the two-year mark. It's also how dedicated is the child? How interested are they in wearing it? What are their goals? How dedicated are their parents to making sure they're practicing wearing it, putting it on, et cetera? Previous studies, now this is before all of these things were available, have shown a mean rejection rate of about 35% for upper limb myoelectric prostheses in children specifically. Looking at these, you can't argue that there is a lower cost, which could increase accessibility. The difference between, even if you paid out of pocket, $8,000 versus $100,000, and if your copay is 20% of that, that's going to be a lot higher. Also they're lighter. The Hero arm that I first showed, that only weighs 12 ounces. So compared to a typical myoelectric prosthesis, they're a lot lighter, which means they're a lot easier for children to use, as well as, like I mentioned earlier, people who might have a very short residual limb. It also has, it's easy to print these replacement parts because it is 3D printed. Unfortunately, there's also a lower grip strength and decreased durability, which might be why a lot of them offer warranties. As these studies say, there's an idea that it will promote more social confidence in some of these children who might be bullied or excluded because they have a different arm. Most of the designs are customizable. And like I mentioned with the TrueLimb, the last one I showed, that one was skin color, but like you can get some design on the skin, but it's not interchangeable like the other two are. Now previously we've always thought, and the data has shown this, that simplest is best. The more straightforward the prosthesis, the more likely they are to accept it and not reject using the prosthesis. But who knows, maybe that can change as this technology is more used around the world. So these are my references and I can, anybody's interested, you can chat me and I will send them to you. And I would love to hear any questions or if anyone has any feedback or has used these before. I think we've got some time for questions, I believe. Yeah, I am looking at the chat and can help with those questions. They each use a different intake sensor. That's a question. Yeah. So the TrueLimb uses the topographic sensors and if you go to any conferences, you can actually try one out and kind of see what that means. I was a little, I was like, wait, what, it's not EMG? So that's, that one is the one that's different. The Limitless Solutions and the Hero Arm both use EMG sensors. I think the Limitless Solutions, as you can see, they were external, like it's a sticker that you attach it to. So kind of like your cardiac monitoring sensor versus something that's embedded in the socket. So there's a follow-up question to that. Is any idea if it would be more difficult to train from one to another if a kid already has one type that they use and they are looking to change to another type? That's a great question. I don't know. I haven't had that experience yet. I have some folks that are in the process of getting some of these, but none that has had one and then has switched to another. So yeah, that's a really good question. But all of them, I believe, I don't have, yeah, I think all of them do utilize some sort of like a gaming technology or an app to train. So they're quite intuitive. And actually there's a couple of, if anybody follows Stump Kitchen, the woman who does Stump Kitchen is a congenital below elbow amputee. She does vegan cooking on videos and she actually documented her whole process of being fit with the Unlimited Tomorrow TrueLimb arm. And it's kind of fun to watch because you get to see her do the scanning, you get to see her trying on the different sockets, choosing the skin color, learning how to use it. So it's kind of, that's one way that you can kind of see a little bit more about what the process is like. Okay. What are your practices and recommended replacement schedule to accommodate growth while minimizing out of pocket costs? The million dollar question. Yeah. You know what? That's really, really hard. I, for me, so in general, I'll tell you about like prosthetics in general. I can't, like I said, I can't speak to these in particular because I haven't had enough patients that have actually been fitted with them for longer term that a lot of these are very new products. In general, document, document, document. If you can document, especially as we treat children, that they have had growth, that they are having socket problems, you know, despite having like your typical adjustment schedule, then I've not really had a problem with insurance covering things. It's when you don't document, like if someone, the therapist or the family reaches out to you and says, Hey, and you have a problem, can you put in an order for replacement this or adjustment that, and you haven't seen them in a while and nothing's documented. That's when I find that the prosthetist is calling me saying, Hey, I need more documentation. So I would just say, make sure that if you feel like it's outside of the realm of the normal schedule, just have them come back and see you in clinic. Yeah. Do these companies have a growing program and like the 3D molding, would it be, shouldn't it be easier to accommodate growth or is that something that you haven't heard of yet? Hypothetically it is. I know one that I mentioned, it's the Trulim has like a 50% off discount if you outgrow one within the like each year. So they do try and accommodate, they know they're fitting children that are kind of a moving target as far as growth. So I would say most of them are pretty accommodating when it comes to that. And I think the ease of 3D printing makes that a lot more facilitated in general than your typical bioelectric prosthesis. You mentioned multiple times that there is no OT training component for most, all of these devices. Is there a concern about skin breakdown or any particular cons, the lack of therapist supervision that you've already come across? Yes. I think we're waiting for that. I mean, I was, as I think a few folks like Glenda, like I was trained at a Shriners where I was standing next to the OT, standing next to the prosthetist and the three of us were seeing this patient together and making sure is the cant right? Is the angle correct? Is this right for this patient? Is the socket fitting? And I just, I, the world with no OT does not make sense to me because these are so fine-tuned. Now, I don't know what their pre-production phases look like. Did they have an OT involved before? Maybe, I don't know, but you know, with building these apps and things like that, but I find that problematic for me. And then because they created all these apps, OTs, like I said, aren't familiar with them. So they're like, I can have them practice with it, but they can practice with it with the app as well. So it's, it's, it's problematic for sure. Yeah. You mentioned also that you typically start prosthetics around two. And is that an age two or developmental two is one question. And then the other one is a lot of these don't start until six or seven. So what is your criteria as a provider that you're thinking about before going this myoelectric route? What are you kind of thinking about? Like, should I be talking about this with my patient or should we be sticking with like, what are our typical things that we usually speak about? So I would say the data is more has to do with typical developmentally age two is because the data was not looking at children who have developmental delay or intellectual disabilities. It was purely looking at children with a congenital limb difference. And the idea being that if you fit them before they're age two, you know, by, by age two to three is when we're developing more of our sense of self in our bodies and knowing where my body ends and yours begins. And so the idea was more one of, at least the theory is that it has more to do with your own understanding of your body and your acceptance of, oh, this is just a part of my body that I'm going to wear it all the time. So I don't necessarily fit all children before two in general. I have like a lot of long conversations with families, with children with upper limb congenital limb difference about, do they want to fit? Do they not want to fit? I explained to them, it's a long process that you have to work with OT and make sure they understand what it entails and tell, especially if it's a unilateral upper limb and say, you know, this is really a personal decision. People are going to tell you what to do. There's no wrong or right answer. And so for me, it's a very kind of individual decision. As far as myoelectric prosthesis, you know, in my experience, the children who are really good wearers of body powered are going to be good wearers of myoelectrics. And the children who can't even keep a body powered arm on are probably not going to wear a myoelectric arm either. And so this is just my personal philosophy is that I want to see them with a good wear pattern fitting well between those ages, if parents are really gung ho about fitting between two until they get old enough that they might want to do these prostheses. Now, I don't push these on anybody. It's more when parents come to me asking for them that we have that conversation. But I want to see them be a good body powered wearer before we bump up to the myoelectric. And as you all know, it's hard to get things paid for by for children. Yeah. And I think it's but with TikTok and Instagram and all these things, like, are you seeing it more? Are you seeing more families being like, hey, we saw this online? Like what do you know? Like, is that increasing? I wanted to do this talk because I wanted to, like, delve into it myself, too. Yeah. So one more question, and then we're going to have to go on to the next talk. But how does use of these options fit into your practice habits compared to traditional prostheses? So I think you kind of already went over that, that you kind of wait for them to bring it up. But is there a first line for you or more of alternative when traditional prostheses are not reimbursed or not appropriate? Um, not necessarily, I think it's it's it's what the it's really a personal conversation with the families on what are their goals. And if they are just like, we really want to do a myoelectric, then I would probably, I mean, for me, it would probably be but being in California, I'm nowhere near Florida, so I don't really think my patients would qualify be as easily able to travel all the way to University of Central Florida. So I would probably be between either the true limb or the hero arm. The benefit of the hero arm is it can be built to insurance and so you know, versus the out of pocket costs, you know, so it's, but I don't know that I necessarily have a preference per se. I haven't I want to see some data first and that's that's my problem is I'm just I'm waiting for them to show us some of these outcomes like do the kids keep wearing them? Do they do they wear them every day? How you know, are they functional or not? And I'll put my email in the chat. So if anybody has other questions, you can feel free to email me later, or if we have time. Thanks, Dr. Phoebe Scott Weir. Thank you so much for your talk. That was wonderful and very informative and very helpful. And I'm glad that it sparked a lot of questions kind of at the end about practice. And this is something that I think will come up more and more in all of our clinics and just having that information is really, really helpful. So I am going to pass it along to Dr. Kivlahan for the next part of this. And then if people stick around at the end, they can always have questions come up kind of answer those as well. Great, so we are ready to move on to our next talk. So I am happy to introduce Dr. Vera Setlana. Dr. Setlana received her medical degree from the Russian State Medical University and completed her physical medicine and rehabilitation residency training at the New York Presbyterian Columbia and Cornell program. And she is now currently finishing her first year of her pediatric rehab medicine fellowship at NYP Columbia as well. She has a background working as an attending physician in academic pediatric oncology in Moscow, and has special interest in pediatric cancer rehabilitation. Her other interests include orthotic management and the biomechanics of gait. She is a co-founder and serves as a pediatric advisor for the Russian Smith-McGuinness syndrome community. And she will be speaking today about considerations for shoes and shoe modifications as part of orthotic interventions. Hi, everyone. Thanks so much for a lovely introduction. And can you see my slides? And can you hear me? Okay. Yes. Great. Okay. Beautiful. So wait. Okay, that's my real first slide. Alright, so I will be talking about shoes today. And I got very interested in this topic, because I did indeed feel like we don't talk about this enough, and don't think about this enough. And patients with neurological and musculoskeletal disorders, at risk for food deformities. And I think it's very important to provide them with the best possible footwear to make sure they're taking those steps and staying active and avoiding the conditioning. And I will be talking today about the considerations for shoes and shoe modifications that can allow us to achieve the best possible results and outcomes when used in conjunction with bracing. I have no disclosures. And in terms of the objectives of my talk today, I will review the most common indications for shoe modifications in pediatric population, list the obstacles preventing providers from prescribing appropriate shoewear, promote discussion about this topic with the goal to put an action plan in place. And yeah, we'll talk about each of those components in more details. So our patients frequently require orthosis to improve their gait and stability and balance. And orthosis or an orthotic device is defined by the International Standards Organization as externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system. Shoes that go with the lower extremity orthosis oftentimes are an essential component of their orthotic intervention, or occasionally the shoes themselves, if they have certain modification, can play a role similar to an orthosis. One of the goals when rehabilitating the patients is to optimize forces and moments acting on the bones, ligaments, and joints during the standing and walking to allow for the most natural gait pattern and the least energy expenditure possible. There are a few commercial shoe options on the market that are deep and roomy enough to accommodate the braces. Depending on the piece, those commercially available shoes would require external or internal modifications. And on this picture, you can see the shoes of one of our patients, which were modified because he has severe plantar flexion contracture. Now, the next slide is indications for footwear modifications. And there are multiple. I would start with leg length discrepancy. And I can't emphasize how important it is, I think, to correct that leg length discrepancy starting from early in childhood. There is a study from Finland, I think, that they actually basically studied patients with leg length discrepancy, and they have proven that the longer leg is three times more often requiring knee and hip joint replacements due to early signs of arthritis. So it's important, and yes, we're taught that not every leg length discrepancy is needed to be corrected. And if it's not too big, we sometimes kind of let it go. But in reality, it's very important to make sure that if we can, we do correct for it. The next indication is severe plantar flexion contractures, and we deal with this a lot in pediatric rehab medicine, and we're trying to avoid this as much as possible. Of course, there are cases where it's difficult and patients still have plantar flexion contractures. And in those cases, we do need to modify their shoes and basically bring their ground up to their heel to give them support to avoid foot pain and avoid foot deformities and allow for normal gait pattern. The next indication is interesting. So basically, it's different indications requiring a custom rocker. For the most part, those are either ankle fusions, cases when the ankle was fused, or it's cases when we gave someone a solid AFO, which is basically imitating an ankle fusion in this case. And then especially if we gave them a solid AFO, or actually maybe even an articulated AFO. But if we gave them the AFO with a full foot plate, meaning that the plastic goes all the way down to the toes, so we eliminated all the natural rockers of gait, then we do need to provide them a custom rocker on their shoe to allow them to have a full gait cycle. If they're doing stepping pattern, it's a different case, and we'll talk a little bit more about that in the future. The next indication is arthrosis tuning. Again, I will talk in more details about this, but basically, tuning is the process of making sure that the shank and the thigh is aligned in the correct manner during the stance phase of the gait. For the most part, we do need some form of gait analysis for tuning, and it's indicated for most of the braces. The next indication is cases of excessive pronation or supination. Those can be achieved by either giving a heel wedge, middle wedge, lateral wedge, or a foot flare on the side. And then, foot amputations and congenital malformations of the toes and the foot also require some shoe modifications. Now going into types of shoe modifications, heel lift is pretty easy to understand. I don't have a picture for that. Foot elevation, so that would be for leg length discrepancy. Here in the middle, you can see the hiking shoe with quite a bit of elevation. Then the sole modifications could have wedges or flares. Here in the bottom, you have middle and lateral wedge. If it would be on the outer side, that would be called a flare, and it also can, as we discussed prior, it can help with excessive supination or pronation. And then rocker sole, if you take a look over here on the top, so this is the shoe prior to modification, and on the right, this is after the modification. And the difference is, I know they both are white, sorry about that, but basically the difference here is that here the sole is mostly flat. It has a little bit of the rounded ending in the very end here, maybe like the last 5% or 10%, but here the end of the rocker is starting at three quarters of the length. So all this is the rocker, and it's imitating the third and fourth rocker of the gait. Then we can do shoe widening and bulges for deformities and brace accommodations. That's a little bit more complex, but could be done. And for diabetes, this is done frequently. And then shoe orthotic with toe fillers for amputees and congenital trauma formations. The goals of the shoe modifications is actually very similar. As I was preparing for this presentation, I realized that the goals for shoe modifications is basically the same as for bracing. So we want to help control biomechanical alignment of the foot and ankle in locomotion. We want to redistribute pressures on the feet and protect the foot and ankle during the gait. We want to produce a more energy efficient gait pattern, provide wider base of support and stability if needed, and minimize long-term effects of walking on the feet. Just to go into a few examples of how shoe modifications could be done, one of the most frequent diagnoses, I mean it's a rare disease overall, but it does most of the times I understand require shoe modifications, Duchenne muscular dystrophy. So we know that boys with Duchenne muscular dystrophy start walking pretty early and then eventually they develop heel cord contractures. We are taught not to correct those contractures, or at least not to surgically correct those contractures, because they do toe walk. The reason why they toe walk is basically to allow, to compensate for hip extensors so that they can shift their center of mass forward. That's the reason why they're toe walking. So we don't want them to correct their toe walking, or even if we do correct their toe walking, then we will need to give them the shoe lift to allow for that shift of center of gravity forward to allow for them to make the step. Eventually those kids will require bracing, and this is actually H.K. Full of our Duchenne muscular dystrophy patient at Blightdale, and this is his shoes by the way, which were modified for him. And once they need bracing, then again, tuning is very important because you want to achieve the alignment that accommodates any contractures but at the same time allows the child to have forward center of mass to balance over the base of support, as I mentioned. So it's just important to think about those things to make sure that if we're giving them the braces, if we're giving them the shoes, they're serving them best. In terms of the tuning, just going into a little bit more details about that, this is pictures from Elaine Owen's algorithm. I attended her course in the last fall, which was actually excellent, and I highly recommend if someone has time and opportunity to do it. She talks a lot about tuning and importance of it, and I just wanted to, I grabbed a few pictures from her manual to show you. So let's say, so the whole, so the tuning process again is making sure that the shank is, and shank meaning the lower leg, is aligned in the proper manner to the vertical. So shank to vertical alignment is correct throughout the gait cycle, throughout the stance phase. And in order for that to happen, a few things have to be properly aligned. And shoes frequently need to be modified in order to make sure those angles are actually the ones that are needed for the best gait possible. So that's tuning process. Oftentimes it requires shoe modifications, but also oftentimes it could be making adjustments to the brace, changing the trim lines a little bit, changing the plastic or making different adjustments if it's an articulated brace, then maybe changing the plant reflection stop and things like that. But overall, this whole process is called tuning. And in terms of considerations for the shoes in regards to that, there are a few things. So let's say you have someone, you're giving the brace with a three quarter foot plate. Three quarter foot plate, meaning that their metatarsophalangeal joint is free. So they do have their natural third and fourth rocker, third, sorry, being the MTP joints and the fourth being the toes. So for those patients, you actually want to choose the shoe on the left over here that would be flexible enough so that it can bend and they can use that natural rocker that they have. And then think differently if we have someone who we're giving the shoe with a full foot plate, meaning that it's plastic, firm plastic throughout the whole foot. Then if we want them to achieve full gait cycle, then we do have to provide them with an artificial rocker that is simulating the natural rockers to allow for that rollover shape. And those down below, there's examples of different rockers. It can be a rounded rocker, it can be a point loading rocker. This is called point loading rocker when there is kind of like a firm point when the forces are changing. And with a rounded rocker, the forces are kind of sliding along the bottom of the foot. So that was tuning. And then just a few examples of tuning and why it could be important for our patients. I think it's mostly applicable for patients with crouched gait with cerebral palsy. So here on the top, again, those are pictures from Elaine Owens. She owns them. But here, there are pictures of the boy walking. He has earphones on and shoes on. And this picture on the left is before tuning and picture on the right after tuning. So if you see here, the white point here is the ground reaction force. So here, he's in mid stance. Mid stance meaning that knee is over the foot and hip is over the knee. So this is mid stance. And here, ideally, the ground reaction force has to go through the knee up to the thigh and be kind of vertical. And in his case, it goes up here anterior to the knee. So this forces the knee, actually, in recrobatum. And here, after the tuning process was done, now the alignment is correct and there is no recrobatum anymore. That allows for a better gait. And here, another kiddo. This is actually, I think, true crouch. And here, sorry, the pictures are a little small. But the idea here is that, again, this is prior to tuning and this is after tuning. So the ground reaction force over here, it actually is going vertical. So that's good. But the problem is that it actually is behind the knee. So that causes the knee to flex, to bend, and hip to bend instead of extending. So you can see here that he's walking, actually, pretty well. But the problem is that his hip is not fully extending and his stride length is short. And after tuning process was done, the forces are aligned better. And this allows for good hip extension and longer stride. So that's the goal. That's the goal. And the idea is that to achieve those, oftentimes, you need to add a little bit of a heel lift on the shoe so that it pushes the shank a little bit forward. So this would require a shoe modification. Occasionally, this can be done with a brace itself and not with a shoe. But sometimes, it needs to be a shoe. So now the fun part. Actually, the shoes and the shoes that we use and we like. So there are a few. We like New Balance. So New Balance are here on the top. So those are good because they're roomy and deep enough. The downside is that they have laces. So you do need to untie the laces in order to squeeze the brace and the foot in. But they're good. And they do hold the foot pretty well. They do have a small rocker. Not a big one. Not as big as Hawkers. Hawkers are famous because they do have those great rockers. Almost as good as in the MBT shoes. Actually, MBT shoes, those are only adult shoes as of now, at least. But those are used by patients with ankle fusion. Adults, patients with ankle fusion. I actually was looking into that while I was preparing for this and just was following them on a few forums that they discussed this. And it looks like they all like MBT shoes quite a bit. And it makes sense because it allows them to have a good rocker. So Hawkers also have a pretty decent rocker, you can see. But more stability, I'm guessing, than MBT shoes, if we're thinking cerebral palsy kids. And New Balance has a little bit of a rocker, but not a really big one. And then Billy's. So we do like Billy's a lot. We like them because they have a zipper and it's very easy to get the brace in. The downside is they don't have a rocker at all. Their sole is completely flat. I did find one shoe in Billy's that did have a little bit of a rocker here. A little bit, we can say. But I think the brace would be harder to fit in. So that's what I found in terms of the shoes. In Billy's, I wanted to mention, I don't know if everyone knows this, but they were created by a patient with an SCI. Actually, it's cervical level SCI, complete injury, who wanted to be able to put his shoes on. So that's how those were created. Okay. And now in terms of the coverage for the shoes, basically average market price for shoe modification, at least for a child, it sounds like it's about $100. It can be more, it can be less, but that's what most likely it will cost if one of our parents will go to a shoemaker and ask them to add, for example, a foot elevation for leg length discrepancy. Considering kids growing really fast, and usually we remodel their braces every six months, usually that means that the shoe needs to be changed every six months. So if you think of someone who has leg length discrepancy, for example, and for 18 years of their life, their parents will spend $3,600 just in shoe modifications on top of the price for their shoe wear. I think that's quite a bit of cost. And I just started to look into how this can be built through insurance and stuff. So here's what I found. And yeah, this is just a slide saying that coverage from insurance is pretty limited. And oftentimes it ends up patients and their families paying for those shoe modifications out of pocket, which creates burden on them. And then as a result, unfortunately, it makes providers more hesitant to recommend the shoe modifications despite those being indicated in certain circumstances. So I started looking into the coverage for it in terms of the insurance. So this is what Medicare and Medicaid website says. So basically, shoes can be covered if they're an integral part of the covered brace and if they're medically necessary for the proper functioning of the brace. So this is a little bit vague. It says that it has to be an integral part of the covered brace, but at the same time necessary for proper functioning of the brace. So if you look at it that both of those have to happen, then neither of our cases would be covered. However, if you look at it as if this is the shoe that is necessary for the proper functioning of the brace, then you have a case that the shoe actually should be covered and shoe modification should be covered. It says the same thing about the inserts and other shoe modifications. So this was about the shoes themselves and the codes about shoe modifications. So they're covered if they're on a shoe that is an integral part of the covered brace and if they're medically necessary for the proper functioning of the brace. Now let's go to the private insurance coverage. Sorry, a little bit of a busy slide, but I just want to interrupt you just a few more minutes because we are running short of time. Okay. Yeah, sure. I'm almost done. Yeah. So in terms of the private insurances, Aetna is the best at this. Basically, at least on the website, it says that it will cover the brace and the matching shoe as long as it is built on the same time. Blue Cross Blue Shield is similar to Medicare and Medicaid. Cigna only covers if the shoe indication is diabetes or vascular disease. And United is pretty strict about that the shoe has to be permanently attached to the brace. And then I, as I was preparing for this, I was trying to find an orthotist who actually does shoe modifications and I did find one in Seattle. It's Catherine Davis and she is actually listening to this talk as well. She works with Christy Bjornsson and she provided with the codes that they're using for the, to get reimbursed, the shoes and the shoe modifications. So here you can see the codes that they use. And she says that most of the times they do get them covered. And oftentimes they do get the shoes covered as well. The caveat to that is that it has to be, the provider has to see the patient in person and the script has to be written for the shoe and for the brace. And I just wanted to finish saying that I wanted to initiate the discussion about this because I think that it sounds like the coverage for the shoes is very limited and it kind of ties our hands in terms of what we can prescribe and how we can act on this. And I just wanted to see if there is anyone amongst the listeners who would be willing to get together and discuss this and hopefully advocate for better coverage. And this is all I have. Those are my references and thank you so much for your time and for listening. Thank you so much. So you knew what kind of questions the audience was going to ask because you ended up answering a lot of the ones that you had already, you ended up answering a lot of the ones that had already been asked, but a couple other ones were what for correcting with a shoe lift, what leg length difference are you usually doing that for? How much? Yeah, I actually haven't seen, unfortunately, this done much. We have one patient who has two centimeter difference or two and a half centimeter difference, almost an inch, who I know that his mom brings the shoe to the shoemaker and that's what she does. I think that's the only patient that I've seen that just at Columbia through the short amount of time that I've been kind of looking at this and paying more attention to this, but that's what I've seen. Another question is about correcting foot positioning for Duchenne muscular dystrophy patients. So have the thoughts about not correcting the foot position in patients with Duchenne changed at all for those receiving gene therapies? And does the weight of those braces, does the weight of the braces and those with plantar flexion contractures important to consider given the weakness that's present? So in terms of the gene therapy, I actually don't know because I think this would depend on how they clinically present because as they start to walking, if they do start to walking, then it means that their weakness is enough to make it difficult for them to walk. So I don't know. Make it difficult for them to walk. In terms of the weight of the braces, again, I think it depends. The braces, my understanding is needed when they need more support and when they need the support for the knee in order not to collapse. I don't believe you need the brace while they're just walking because I think as they just start walking, you want to give them the shoe with the shoe lift to just bring the ground to them so that it's easier for them to walk and so that they don't need to put so much weight on their toes and kind of like constantly deforming their foot by doing that, if that makes sense. But I don't believe that if they just walk, they need the braces. That's correct. Yeah, and then there's some comments that some of the patients with Duchenne who have had gene therapy are typically able to be managed with some nighttime stretching braces too. But still, I think we're all getting used to seeing more and more of those patients, so time will tell. Another question on your experience if you've used Nike FlyEase shoes. I've seen them. We haven't used them, but I've seen them and they look really, really cool. I don't know if they do them for kids though, if they have small sizes, but I've seen them on the website and it makes total sense to use them. They do. So there's a great reference from the Spina Bifida Association. There's an AFO guide that has the type of AFO and then a recommendation for shoe for pediatric patients, and it actually goes by age. So a lot of times I'll refer my patients to be like, I know you don't have Spina Bifida, but the association made this awesome resource, so check it out. So you should look at it too, but it's a great resource for families. We use them, but mostly Billy because we rise with us. So we use them, but mostly we use Billy's for kids, little ones, but for older ones, we use FlyAway. FlyEasy, FlyEva. One question discussing shoes for our very little kids, and if anyone has any resources for using very tiny shoes with some difficulty finding the right shoes for our smaller kids. Well, I think 10 littles would be good. That's just from my experience, because that's what my son, who is one year old right now, wears, and I was thinking a lot about it. We have one kid actually at daycare who has braces and he has some littles on, and I like how it fits. I like how it holds, so it's pretty good. They are not the zipper. They have the Velcro, and they're very easy to put on, so I think that should work. Any luck with getting shoes covered like Billy's when it's more of a convenience for carers and the parents doffing or dotting, or when you're talking about insurance, is that mostly for shoes that have been truly modified for a medical reason or for a shoe lift? Well, maybe Catherine Davis would be a better person to answer this, but my understanding is that you can try. I mean, you mean if they don't have braces at all? No, just for convenience. Yeah, I'll go ahead and chime in. So I'm also working with some of the Seattle Public School physical therapists, and we're kind of in a gray area deciding how we're going to get the Billy shoes reimbursed. I don't always do modifications on those shoes, but if I can justify to the insurance company, especially if I put it in the same claim, that the shoes are needed to accommodate the bulk of the brace because otherwise they can't use the brace, then I've had some luck getting them covered in that circumstance. And the way we bill for orthopedic shoes, it's a code. We don't specify what type of style or anything that we're ordering, so that gives us some flexibility in terms of what we do, and then it's kind of up to our discretion if we're going to do modifications and bill for those. But just I think really being specific in the language about the purpose of the shoes and that without them, the child's not going to benefit from the orthotic intervention. Those tend to be some good buzzwords for getting insurance coverage. You also answered another question earlier about the five-eighths under, five-eighths in a shoe, but typically if it's greater than five-eighths difference, it's outside of a shoe. Is that the amount that you're correcting or the amount leg length difference? Because I've heard different things about, you don't correct the entire leg length difference, you're only correcting like a percentage of it. So the way that I've dealt with leg length correction is, I mean, you have to think about the heel drop in the shoe as well, because if it's a zero drop, you're going to have to put more of a lift. If it's more, you have to put less of a lift. I really, we kind of gauge it on the pelvic obliquity and just trying to remove that and the individual. So that's a tough one to answer. I don't know that I've ever thought of it as a percentage or just in terms of restoring pelvic balance, depending on whatever shoes that they're wearing. Do you recommend any products for kids who need different size shoes for each foot? I think someone was saying Bekos, Nordstrom does some of that too, I think, yeah, Nordstrom. And then what is usually the process, you know, if we were going to try to get a shoe covered that is typically bought commercially, do we submit the order to insurance and see if they're willing to cover that commercial item, or does the family try to later get it reimbursed? So for us, we, every clinic is a little different. We typically, so we submit billing codes for like authorization, sometimes an authorization isn't required. We don't actually do the billing until the device is delivered. So sometimes, unfortunately, we will bill out and then get take back, and then we just have to eat the cost. But again, we don't specify, you know, what shoes we're getting, we could be using Mount Eni and Aethas, or Drew shoes, or Billy shoes, that is inconsequential, in my opinion. I don't, I don't really give that, it's only mentioned in my chart, I think. So it's, it's not a, it's definitely not a perfect system, and there's a lot of room to improve. And our clinic right here is struggling to figure out the best way to give these children access to the shoe wear that they need, while also not having to eat the cost over and over, and then actually not making any kind of profit. Great, and a couple extra resources in the chat about some places for families that need different shoe sizes. But I think that was all the questions I saw so far. We are just about at time. Thank you all for facilitating those questions. You did my job for me, so I appreciate it, but we will be sure to share any resources as well. And I'll just allow any final thoughts. Thank you, everyone, for being here today was a great discussion. Dr. Hartman has one slide to share and after that, we are done. Yeah, sorry, I put it in the chat as well real fast. We are going to be holding a call for community leadership positions that are open starting in the fall. So we'll have three positions open, two or two year terms, the chair and vice chair. So Hannah and my positions, and then a one year trainee vice chair position which Debbie is holding right now, applications or nominations will open at the end of the month, but we'll send more information about what each position entails and how to do that later this month. But if you're interested, just kind of keep that on your radar. Thank you, everyone.

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