This is Megan from AAPMNR. I am not Mary, who is unable to join us at the beginning, so I am going to start with an enthusiastic welcome for Dr. Rosenberg, who is Professor of Pediatric Physical Medicine Rehabilitation at Nationwide Children's Hospital. We are thrilled to hear his talk about evidence-based outcome predictions in pediatric traumatic brain injury and spinal cord injury. So I'm going to turn off my camera and let Dr. Rosenberg take the helm. Thanks. Appreciate it. Hey, do you guys have voice access? Do you want to jump in and talk, or is it just the chat part? We'll see. Welcome, everybody. Hi. This will be a fun hour, a good time. I'm looking at this attendees list right now to see, because there's names I recognize. I'm not going to say hi to every one of you that I'm excited to see, but I just saw Michelle Potts pop up on the list, and there's Becky Siegel, and Elizabeth Moberg-Wolf, which, by the way, if you're watching video, Elizabeth, look behind me. There's our guy. There he is. So we are a small enough group and a small enough field that my hope is that we will be active in chat, and if you can use your voice, just interrupt me and jump in so that we can talk about this. This is my favorite topic to talk about, and so I will constantly talk for an hour, but that's not what we have to do, so stop and interrupt me. I would love to have conversations, and I learn a lot when I give this talk, and so there's a lot of enlightening things, and there's some new slides in here based on what I've learned since having conversations with people, so please jump in. Jump in the chat. If the system allows you to jump in on voice, just start talking, and that's cool with me. One caveat before we get going, as Mary and I were planning this talk, the word predictions didn't sneak in, and so there's evidence-based outcomes for what you can do, and then the bigger thing is that what I hope to focus on today is how do we predict things, so I have nothing to disclose. Here are some objectives. This is what we do, so we're going to talk about tools to predict outcomes using evidence from brain injury, spinal cord injury, talk about heterogeneity of traumatic brain injury outcomes, and the challenge of early prognostication that I would guess we've all faced, and then tools available, so how do you communicate findings to families? That's one of my favorite ones because it's surprising what people say compared to what physicians say. It's really interesting. There's one more thing we're going to do today. We're going to determine if you guys think you're smarter than a robot, and those slides will go up pretty soon. It'd be a good time. If you don't mind in chat, jump in the chat, and please just throw in where you are in your life, like what city you work in. If you're not in that city that you work in, tell us that too, like if you're hanging out in like Curaçao or something or someplace, I don't know. Please throw that in the chat, and also if you are in training or if you're an attending physician or something, let us know what you do. Students, yeah, just so I have an idea of who I'm talking to, that would be great. Okay, so I work at Nationwide Children's Hospital. It's a big hospital. It's right over there out this window from where I sit. The big building is, every time I give this talk, I have to increase the number of beds. It's now 699, and they're going to build a new tower, so I just have to look it up every time. Big, big trauma volume, and so the, we get PM&R consults on admission for all level one traumas. It's still a discretionary consult, but they usually, their discretion is to say, press the consult button. We have a 12-bed inpatient rehab unit, but on the side, I do the dad thing, and I've got a great wife, and I run on trails. I started doing that in COVID, and then I'm like, I'm a really bad banjo player, and if there are any bad banjo players out there, I would love to join you guys. I see Elizabeth Moberg-Wolf coming in, chiming in from Milwaukee. I'm a Milwaukeean by birth, and that's, again, why you'll see many references to Giannis, my favorite guy. There he is. There's Giannis, so Giannis, after he won the NBA championship, ordered a 50-piece chicken minis, 50 exactly. It was a fun video to watch, but I want you guys to interrupt, just like, you know, this is an interruption to my talk, too, but I want you to interrupt, too, so jump in the chat. I will be watching the chat. I have the window up there, seeing comments from people, including Jordan Wira, who just commented, but I would love, if you guys have questions or comments, or you want to disagree with me, please do so. This should be as interactive as possible, so game plan here. I'm going to have two cases. We'll talk about prognostication in brain injury and spinal cord injury, and then talk about how do you communicate prognosis, review how these two cases, all the cases turned out, and then a summary slide, and then, so a recent addition, are you smarter than a robot? So biggest overarching question here is that people want to know what's going to happen, so we see a large trauma, whether it's spine or brain trauma, and families look you in the eye, and they say they want to know what's going to happen, and what do we have that's better than a crystal ball to actually give them something, because I think physician ego, and just I think I know, is not, doesn't really suit the world of 2022. So quick thing, we know our TBI definitions, this audience, I give this talk to a bunch of different audiences, so some slides will just go through, we know what a severe TBI is, this is what we're talking about, and so there's this challenge of the patients pretty early in their medical course with severe brain injury and or spinal cord injury, so in severe brain injury, thinking about the ones that aren't following commands within the first week, that are not, their arousal is low, spinal cord injury, I think that's all comers, and so I started giving this talk because a lot of colleagues said, said well what do you think is going to happen, how are they going to do, and the parents they want to know more broadly what's going to happen to my child, and then what I do is I say well okay how do I use literature to inform this conversation, so because I felt like I was just sitting there saying well I you know kind of know, maybe I can guess, that wasn't good enough for me at least, so what do people ask about early, I think you guys I'm talking preaching to the choir here, that people want to know about walking, they use the phrase confined to a wheelchair, I put that in quotes because I think we can all agree that that statement, that phrasing is just brutal, and that I don't actually use it, people say will they be able to speak and when in traumatic brain injury, and then the bigger thing if they want to get larger scoping is about community independence, so will they eventually move out of my house, am I going to help them when they're older, which is a question for those of us that have teenagers or preteens, can't ever think that they would ever move out of your house ever, ever, I don't want them to, I'm just saying couldn't they, so case number one here, this is Adam, this is not his real name, but it is a very real case, so I have consent from his parents to teach with the case, and he Adam fell off a scooter and hit his head, scooter was going really fast, he was taken to an outside hospital, he was intubated, transferred to Nationwide Children's, we get a head CT because that's what we do, oh there it is, and you can see that there is some left frontal hemorrhage, and oh Scott Paul this is great, they move out, the cool thing is they have their own homes and kids, we only hope so right, I'm going to believe you, but it's hard, it's hard, I'm just going to believe you, so looking at this head CT, I think an important thing to note is that there's not much to see in those ventricles, there isn't much of them, but there's some left frontal hemorrhage, so in the case of Adam, his best Glasgow Coma Scale first 24 hours was 7T, a lot of those exams showed 3T, an ICP monitor was placed on that first day, and ICP intracranial pressure was quite difficult to control using medical management, so we have this next head CT here where you're missing a large segment of bone, so he had a craniectomy, oh there we go, so you'll see that he has a craniectomy, and there's some scatter there, but there also appears to be some hypotenuation of brain. Other things he had, he had cerebral venous sinus thrombosis, he had injuries to his left ACL MCL, medial meniscus, and he had a left metacarpal fracture, put this in your heads and remember left, left metacarpal fracture, that's going to come back, it's going to be really important in a minute, or in 30 minutes, he also had post-traumatic seizures. This is a picture of him, specifically this is him, this is when parents ask what their outcome is going to be, this is what you see. So I'm glad we have consent to show him, and so you can see this is the timing, I think you've all been in this situation, this is when people want us to predict. So his early exam, he's intubated, he's sedated, he's hyporeflexic, he doesn't have pathologic reflexes, he doesn't follow commands, okay. So parents want a conversation about prognosis, so would I, so what tools do you use, do you use imaging, we had his imaging, do you use his exam, do you use his Glasgow Coma Scale, do you use a crystal ball, or I might suggest you can use humility, it might be your best option there, and I'll tell you why in a bit. Here's another case, his name's not Bob, but that's the name I just mentioned, his name's not Bob, but that's the name I chose for him, so Bob fell off the back of a pickup truck when he was 15, or this was 15 year old, the truck was moving quickly, his Glasgow Coma Scale at the scene was 3, early exam somewhere between 3T and 7T, similar to the other case. Here's a head CT with some frontal hemorrhage and some small ventricles, not unlike the other case. Sorry, I went fast through that head CT, so I'm going to go back and make it visible still, take a look at it for a bit, not too different than the other one though. So his best Glasgow Coma Scale in the first 24 hours was probably 7T, I don't have all the data, his ICP was quite difficult to control using medical management, I hope you sense the pattern here because these cases are similar and real cases, so he got a craniectomy on the other side, these are my two most similar cases for presentation, so here we are. I got some feedback that I moved too quickly through imaging, so I sit here and just talk through imaging while you have a chance to look at it now. All right, onward, so Bob also had a metacarpal fracture, I don't know what side, it's not as important as the other metacarpal fracture, he did not have post-traumatic seizures. So early exam is exactly the same as the other exam, I think not very useful in terms of finding things out, and his mother in this case wanted a conversation about prognosis, this is the same slide as the other case, so you're in two situations where they want to have a conversation about prognosis and you say okay what do I use? So what do you use? Well here's our reality, we have patients with very heterogeneous radiographic injury types and locations, so I chose two very similar cases, but it was hard to find two very similar cases, and specifically have two with such contrasting outcomes because these two patients, I'll show you later, had very contrasting outcomes. So it's heterogeneous to start, it's heterogeneous EMS and early ICU experiences, so if you get to the hospital in 20 minutes, that's different than getting to the hospital in four hours, right? I think so. And the other thing is that people come into their brain injury in different situations, so they heterogeneous cognitive and motor function prior to the brain injury, so we have all these variables early. So here's some things we think we know, so the things that we have some evidence to support, so what do we think is, we can pretty much assume that these things show up and we're like all right this is good. So early command following, I'll show one study from one of our peers from the great Stacy Suskauer to suggest that early command following is really good, but yes if they're following commands early, yeah I think we can more confidently say, but the issue here is that when parents really want to know something, it's the ones that aren't following the commands early, that's when we get a bit more vague. So there are lack of complications involving other organ systems, so they have a good liver, they've got good lungs, their heart is nice, their kidneys work well, and stable serial imaging, that's good. So then predictors of poor outcomes, prolonged hypoxia or anoxia, young age, so under three is the, used to be an arbitrary number, there's some more recent evidence coming out suggesting that well supporting that under three is a predictor of poor outcomes, and that under five isn't necessarily like the three to five range, but under three is. Symmetric brain injuries, so you injure say like both thalami, that's not good, and then brain stem injury and herniation, we've got good evidence for that not being good, and then the presence of myoclonus on exam is also one that is a poor prognostic. These are things, you see these things and you can say either the good things or the poor things, and you can be a bit more confident about your answer, but there are so many patients we still see that that don't fit any of these categories. So Scott Paul, a question here about what about method of injury and history of prior injury. Yeah, so I think history of prior injury, we can put that in the predictor of poorer outcomes. I don't see too much of that beyond maybe a concussion history, but like a second severe brain injury, yes, I think I'd be concerned about that, and then the method, there are some things out there in terms of saying like gunshot wounds are different than car accidents, but still I think we still end up with a vague subset of most commonly transportation-related injuries. Oh, high versus low, yeah, good call. Scott, that's an interesting one, the high versus low velocity impact. In what I've looked at before, I think the challenges of the vast majority of folks that fall into the category of we're having a hard time predicting tend to be high velocity accidents, but I love to, I think that may be one we can expunge on together outside the setting because we could talk for hours about that. Scott, where are you located? Maybe we can hang out. Says it somewhere here. Is this Minneapolis, maybe? I can't remember. All right, so weaker predictors of outcomes, so what are we not very sure about? MRIs in general, like does that, is that subdurals versus epidurals versus diffuse axonal injury? We do, we can, all right, D.C. until next spring, then Israel, Scott, nice, cool, okay, well, let's hang out in Israel, let's talk, there will be time for this. So, MRI, so there's some evidence about, yes, if there's diffuse axonal injury of the brainstem, that's not good, but otherwise, like the cerebrum, we don't have much in terms of predictions. Neurosurgical interventions, so did the neurosurgeon taking off part of your skull, is that going to change your outcome? We're not sure, and then the lack of command follow, so if you don't follow commands, is that a bad predictor? We're not sure. So, what we have here is we have a paucity of literature informing outcomes based on early findings, that's what we know. We have a lot of the studies that reaffirm the assumptions we already have, like the ones I've already listed that don't add too much to them because it's hard to, and there's this big subset of patients without prediction models. We've got a few, though. So, there's a great study here from Slovis and Miles out of Dallas in 2018 that said, okay, let's bring all these variables together. So, all right, power, pediatric studies, power, 258, not bad, 258 patients. It's a descriptive cohort study, and so we use the, they use the Glasgow outcome scale, which is the most common one we see in outcome studies, I think, and this dichotomous thing where it's like favorable, so Glasgow outcome scale 4 or 5 versus unfavorable, which is 1, 2, or 3. Next slide will have the Glasgow outcome scale on it. There we go. So, 4 or 5 is a good situation, so moderate disability or good recovery ends up being in the good outcome category, and then 1 through 3 are not. So, that's what they're looking at if they dichotomize them. So, I'm going to quickly jump to what happened. So, if you look at 16 months in severe TBI and moderate, moderate and severe TBI, 84% had favorable outcomes at 16 months. So, what can you conclude from that? That good things happen, a good amount. Taking that a step further, when they discharged from the hospital but not at the 16-month point, 60 of those were still in the unfavorable outcome category. So, out of the hospital, out of acute rehab, still in the unfavorable outcome category, and of those 60, almost half had the favorable outcomes at the 16-month point. So, what can we take from this study? We can say good things do happen in kids with moderate and severe TBI. They don't necessarily happen quickly, though, and they don't necessarily happen by hospital discharge. That's a busy slide, so I'm whipping it up for a minute. So, they looked at a bunch of variables to say, okay, what predicted the unfavorable outcomes? And here's a lot of affirmation of what we think we know. So, younger age, we've seen that. Motor vehicle collision, there's your high velocity probably. ICP monitor placement, CPR required at the scene, okay, and then long hospital stay, all right, I believe that. You can't really use it to predict things early because you don't know how long your hospital stay will be. Longer ventilation time, okay, and seizures. So, this gives us some information. It seems like it confirms what we already think we know. So, here's another study by Suskauer here about time to follow commands. There's a few studies from Stacy's group about time to follow commands and how it could be really useful. So, they got one year follow-up, and I'll give you the short version here. So, using time to follow commands. So, 40 children who were admitted to acute rehab, they had one year follow-up. They used WeFim as the functional outcome. That's great. Cool. So, greater than 85 is considered good. We like WeFim. Question from Jeffrey England about different outcomes, early versus late seizures. In the Dallas study, the one I cited before, that it was the presence of seizures as a yes or no question as it was studied. So, I am afraid I can't answer that, although I do like that question, and then Taryn Davis there about a note about wondering about hospital stay versus ICU stay given rehabilitation admission. I agree. I wonder too. They took the, in that study, they took a admission to hospital discharge time and did not separate it out, although you're talking like we should design a study to take a look at that. But again, the challenge with that is that even if you use those data, they can't really help you predict because you don't have those data till they leave the hospital. And by that time, usually you can make a much better prediction. So again, it's like the first two weeks is when you really want to be able to make a prediction, I feel like. Coming back to the Suskauer study. So there's two variables. There's one that's time to follow commands and the other one's, I apologize, I use post-traumatic amnesia in an abbreviation, so PTA. So post-traumatic amnesia. So the sum of time to follow commands plus days of post-traumatic amnesia. I'll cover post-traumatic amnesia more in a minute. And the thought is that time to follow commands does predict a good outcome. And if you add post-traumatic amnesia, it doesn't really help predict the outcome when you put those two together. So there was a prior study saying that if you can follow commands within 26 days, that you've got a better chance at a good outcome. So looking at this study more, here's the thing about it, that 37 out of 40 kids had a good outcome. So that's aligned pretty well with the study out of Dallas to say that good outcomes happen. Here's the thing. The median time to follow commands was 4.5 days in the study, which again affirms what we think, that if you're following commands in the first week, that's great. But it leaves us still with the question of, the most common prediction question we have is the ones that aren't following those commands. So three children had time to follow commands greater than 26 days in the study, and two of those had a poor outcome. And then the addition of post-traumatic amnesia didn't help predict outcomes in that small subset. The question here is, does this study specifically address the people we're talking about, the ones where we struggled to predict their outcome? I'm not sure it does. And then the other question, if one is not following commands early, does that mean they're going to have a bad outcome? And I don't think we can answer that yet. So here's my gold standard for outcome prediction because they have a lot of long-term data. I will say it's an adult study, and we have evidence to suggest that adults do more poorly than kids. But it's an adult study and uses post-traumatic amnesia, and it is well-powered. And I feel like it is probably a good way to suggest that we're not great at predicting. And I'll explain. So this is a William Walker study, 2010. There's been more since then, which I'll cover too. So 2010 multi-center study, the relationship between post-traumatic amnesia as in making memories and Glasgow outcome scale. And this is an adult study. So 1,332 patients after moderate to severe TBI. Big numbers, good thing. And they use the GOAT and the O-LOG. I hope we're all familiar with those. Hopefully, hopefully. They're post-traumatic amnesia tests. So I will not go into the details for this crowd of the GOAT and the O-LOG, but they're out there. So I'm going to jump quickly to the conclusions here that this study of post-traumatic amnesia lasted fewer than four weeks. The probability of severe disability is low. And I feel like this is a useful one to take a picture of and remember, because this may be the best thing we can say if people aren't following commands and they want a prediction, this is what we have. So if somebody is out of post-traumatic amnesia by four weeks, you can say that. But here's the big thing. That doesn't mean that if it's more than four weeks that you're going to have a poor outcome because it's really if post-traumatic amnesia lasted greater than eight weeks, the probability of a good recovery is low. So what this says to me or my synthesis of this is we can kind of say something at four weeks, but we really can't say anything till eight. Like in terms of saying you have a chance that you have a poor or a more poor prognosis, I'm not sure you can say much until eight weeks. So 56 days in. So question from Amy Shambliss about, can you remind me the difference between moderate disability as in like a good recovery and severe disability? The wording in the Glasgow Outcome Scale is really interesting. And I would suggest just going right back to it. Would somebody mind jumping on the web and posting a Glasgow Outcome Scale link so we can all have it, just take a look at it while we're talking. I don't have it handy with me. And I fear that if I jump on that one and post it, and it just posted in the chat, that I will lose what I'm doing here. So coming back a little bit and we'll, there, there's that. So there's the link there. And hopefully that answers your question well, Amy. And if it doesn't, jump back in the chat and let me know. Thanks, Emily. All right. So we're talking about the eight-week point. We're talking about the eight-week point there. And the probability, if you're post-traumatic amnesia lasts greater than eight weeks, the probability of good recovery is low. But what do they actually mean there? Well, here comes an arrow. So we're on the good recovery scale right there, on the good recovery, one that keeps going down, which I understand. That's the eight-week point. What they're calling low is 30%. And this is adults too. So what they're saying is that if your post-traumatic amnesia lasts beyond eight weeks, your probability of good recovery is low. It is not zero at all. And if you watch that one go down, even at the 84 and 98 day thing, you're still above 10% in terms of probability of a good outcome. So you're that far out in post-traumatic amnesia. So it's difficult to say, I think if we use post-traumatic amnesia as our point, it's difficult to say that you've closed the door on outcomes. Note also the difference in the good category between year one Glasgow Outcome Scale and year two, that that entire line, it's not a line, obviously, it's a curve, that entire curve shifts straight up. So a lot happens between year one and two. So now we have affirmation to say post-traumatic amnesia is likely our strongest tool in terms of prediction and those folks not following commands early. And so this is a 2018 study that used a very similar dataset, same author, William Walker. But what they wanted to do was take a bunch more variables in to say, basically, can we stick this thing in a computer and pop out a better prediction of your outcome? So they wanted to develop a practical prognostic tool. You guys are gonna love the practicality of this tool. It's gonna be great. So 2018 study, same lead author, as I said, five-year follow-up with the Glasgow Outcome Scale. This is a well-designed study and they brought all these variables in and they said, okay, computer, get to work. So the variables that you would want in there, age, sex, prior TBI, as was mentioned, prior TBI, Glasgow Coma Scale, elevated ICP, brain surgery, CT findings, length of stay, all the things that we would want and to say, okay, can we have an algorithm or an equation? And it produced something. It did produce a thing. Here we go, ready? Boom. Huh? Is this hanging out in your white coat pocket? Do you even own a white coat? Is this something that you're gonna carry with you around? So look at on the top there, if you can squint and see it, post-traumatic amnesia is right there. That's the first thing, the first node, then, well, were you productive is one choice or it's like productivity and occupation and education are big ones, so pre-morbid factors. But really, you're not really adding a lot of information by putting all these other variables in here. So the conclusions of the study, I think, are great. So the length of post-traumatic amnesia, which is a clinical marker of injury severity, was by far the most critical outcome determinant. So what this says to me is we looked at a ton of variables and the person not following commands at seven weeks, you're probably not gonna be able to break their outcome until four weeks, eight weeks, potentially, probably eight. And it's okay to be humble about that. I'll talk about that more in a bit. All right, so are we ready to change gears? I'm gonna go from TBI to spinal cord injury and it's not really a direct transition. So I put a Jeopardy question that I saw and I want somebody to throw in the answer if they know it in chat. Just something to do, well, before we switch gears so the transition isn't as abrupt. Trey, there we go! Good answer, the great Trey Anastasio, my guy, all right. Thanks for that Trey answer. Okay, so the next one here is another case is Carl, not actually named Carl, a four-year-old male. He was struck by a pickup truck. The truck was going quickly. He was not moving his legs and he was moving his biceps and wrists and extension. I can see you guys with your spinal cord injury brains on. Okay, well, we know what we see here. He was intubated and so here's his MRI. And his MRI is, this is T2 MRI and his cervical cord looks injured. Yes, so he's moving his biceps and his wrist extensors and his triceps against gravity on exam. He has no movement in lower levels and absent rectal sensation. Yeah, he's an AJA. So C7 A-I-S-A. So mom wants to have a conversation about prognosis. Is he going to walk with? And I think as we know, that's the question people ask. In a bit, more foreshadowing, I'll cover whether that's the question people really should be wondering. Here's another case. This is Ryan, this is 12-4-2017. I saw this spinal cord injury with my eyes through my television. 24-year-old male, he was playing tackle football. He tackled another player. You may know this guy, by the way. This is his real name. I hope this video plays. Come on now. Yes. Take a look at his legs here. Falling, oh. Moving his trunk. Let me just show it again right here. All right, so he rolled over. This is Ryan Shazier here. Can somebody just let me know in the chat whether the video worked? I always want to wonder so I can talk about something you saw. Because I have more videos coming, so hopefully they did. All right, video worked. Thanks, Pepper. So Ryan was transported to a hospital in Cincinnati and a news report suggested he could find himself in a hospital with a spinal cord injury. And a news report suggested he could feel his legs and that there weren't any reports of movement early on. So I made up T9-AIS-B, and that was based on my television watching. I was 120 miles away from that injury, so I wasn't his doctor. So difficult, but this is my guess, I would say. So big questions there. So I'm texting with my friends, is he going to walk when we play football again, are the questions they're asking. So we talked about outcomes in brain injury, then there's the spinal cord injury side of it. We know the spinal cord is complex. It's a multi-organ system affair, the injury itself. I'm preaching to the choir about that. But the structure of the spinal cord, in my eyes, is a lot less complex. It's all right in there, and you either get it all or you don't. And I think that's a pretty rough way of looking at it, but I think that we have better outcome prediction abilities because of the nature of the spinal cord, which is primarily a motor sensory organ. So it's not a cognitive organ, for example. So then the other thing is, can we use a computer to predict what outcomes are, and can they predict better than humans? And we're going to look at that. And then here's something cool. An early age exam still is a great predictor for practical information. That's great. And it has been for, I'm doing some math in my head here, like 40 years plus. So I'll cite a study from 40 years ago that still, I think, plays out clinically pretty well. So you guys remember Johnny Five? I hope you do. You've got to be the right age to remember Johnny Five, and Johnny Five is alive. If you do, just throw in the name of that movie. Trivia is fun. So are you smarter than Johnny Five? Well, it depends on your specialty and your level of training. It actually does. Short Circuit, all right. If you haven't seen Short Circuit, here's some homework. Tell me, send me an email after you see Short Circuit. Such a great movie, or it's just not. So here's a study from 2021 in the Spinal Cord Journal out of France. And what they did is they developed a computer statistical model for community emulation prediction at one year. Super cool. Is that computer model available to us as clinicians? Not cool, because it's not. I went looking for it, tried to get it, couldn't get it. So we can't use it right now, but can the computer be smarter than us? And what they did is they gave the computer these charts, and then basically the computer had age and motor scores off an age like that. It's basically what it had. And then they had physicians where they were like, okay, you get the whole chart. We're gonna hand you the whole chart. You guess whether they're gonna walk it a year or not, or at least you get the chart during the acute care time. You certainly don't get the chart saying that they're ambulatory and acute rehab. So by the way, these were Asia A through C. They did not use AIS grade D in this one at all. And so this is a busy slide too, so I'll take my time on it in terms of this table. But look on the far left, the clinical prediction rule, that's the computer trying to guess ambulation. So they do a pretty good job in AIS grade A, and they do what is a pretty similar job in AIS grade A to PMNR residents and junior attendings and senior attendings, residents not as strong in this case. But as you go down to B and C, the computer doesn't do great, and the physicians don't do as well either. It gets a little bit worse. But I wanna point to one specific point here, and I don't really know what it means, but I know it's in the study. So these are the senior attendings. Come on in, arrows. See this? So the PMNR junior attending is 84% effective for AIS-C, whereas the senior attending is half as much. And similarly in orthopedic surgery, junior attending and senior attendings are 84 and then 68. So that's a big difference right there. What does that mean? Well, I'll let you draw your own conclusions about that. By the way, senior attending is defined as somebody that's been out of training, so out of PMNR residency for greater than 10 years. And I'm proud to say that for a few more months, I'm still a junior attending. So hopefully I'm in the right category, we'll see. I don't know. Or maybe I should just study this more so that I don't have to be in that category. So what they're saying is a computer similar to people and that people, we must have some knowledge, are able to predict spinal cord injuries. And this is how we know. So right here. So it's a study from Maynard in 1979 that was in cervical spinal cord injury and looked at ambulation in the community one year afterwards. And by AIS grade. And this, so what have we really changed in the spinal cord injury care we provide to provide independent community ambulation? Not too much. And this shows because these data still play out. So this is what I use still because that computer model isn't available to me. So AIS A is zero to 5%, B is 50%, C 75, and D greater than 90. So this is the, I hold onto this one tightly and these numbers stick in my head because people do want predictions. And so this Maynard study is still the one I use even though it was written before I was born. I just don't know that too much has changed in terms of spinal cord injury care. These numbers haven't gone up. So we step away for a second to say is ambulation everything? I try to share this study wherever I am, whenever I can talk to people that are here listening. I just love it. So I wanna make sure I mention it. I am preaching to the choir here, but I do like to mention. So choir, 681 people with chronic spinal cord injury were asked two questions via questionnaire. One was, do you think exercise is important? They said, yes. Okay, that's not what I wanna talk about though. The second question was about like magic wanding, having them, you get a magic wand. I don't think it's in those words. So what function would dramatically improve your life? If you're given these choices of arm and hand function and trunk strength and balance and bowel and bladder, which is combined with dysreflexia, not sure, okay, I can understand why. Sexual function, elimination of chronic pain, normal sensation and walking movements. So if you ask the general population what they magic wand, I think that the general population would say walking movement, but you guys are the choir, so you'll know what this will say. Highest priority to folks with tetraplegia, we see walking movement right there at below 10%. And above it, things like bowel, bladder, trunk stability, sexual function, arm and hand function, 50%. Okay, big change. And then an interesting one in folks with paraplegia, there's walking movement still below 20%. Trunk stability, as in sitting, is a higher priority. Sitting well is a higher priority than walking. I'm preaching to the choir, but I can't leave this one alone and sexual function's high, which is why we should talk about sex all the time. So we know some things about traumatic brain injury, spinal cord injury, prognosis. How do we communicate those things? Well, there are studies about that too. So Resigno in 2013, there were 25 children with brain injuries and 25 parents who participated in the study. And this study was entitled Locked Up in this Cage of Absolute Horror. Yes, that was the title of the study. So this is like subjective data about parents talking about their experience about traumatic brain injury prognostication. And the phrase that hung with me a lot in there is that there's this overall sense of negative medical certainty, as in doctors being certain about things when they're not necessarily certain. And it created a fearful or threatening environment that keeps parents from being fully informed. Let that one stick with you a bit, because that's a big deal. That affects care. So what we say in prognostication impacts the care of the child and the family's experience. So parents felt disadvantaged by provider delivery. I think we've experienced this before. I think that we're not alone in knowing this happens. That negative outcome values dominated some providers' talk despite the fact that, shared earlier, that we really can't predict outcomes that early. We can't predict negative ones until beyond eight weeks or at eight weeks. And that framing the child's prognosis with negative medical certainty could damage the parent-provider relationships. Sure, I believe that. Big here, big thing here. The children's outcomes were different from the provider's acute care prognostications. And so what they're saying in this study is people were wrong. Okay, don't want to be wrong. Hopefully not. Here's another study by Quinn. It's another TBI communication study. 16 parents, 20 physicians. I love this one. 82% of parents say they want a numeric estimate or prognosis, as in we want a number. You guys believe that? Is that something that, is that like, I don't know. Usually when I have an audience sitting in front of me that can make noise, they say, no, we don't believe that. Is that true? But that's what they said. They want that. And then 75% of physicians reported that they intentionally omitted numeric estimates. So like point A is not talking to point B here at all. So physicians are intentionally leaving them out, whereas parents are saying we want numeric estimates. Now we don't have a lot of numeric estimates in TBI, I understand, but parents are saying, okay, we want them if you got them. And physicians are saying, you don't want them, even though they do. So both groups did agree here on avoiding false hope. Okay. So take a step back. Let's bring it to the humanity point now. How do you go and communicate findings and prognostications? So they ask you the question, what do you do? Because that was, that was why, this is why I love this topic and why I put this talk together in general is how do you make this an art? How do you make prognostication an art with the data that we have? So step one, listen first and then probably listen second and then listen third. People will tell you, oh, good one, Scott. Let me get to that in a second. So people will tell you what they want. So if you listen, and you nailed it perfectly, Scott, where it's like, listen first. So Scott Paul's comment here is why not try to understand what is behind the parent's desire for numbers and counsel them based on the underlying issues. And you should, you should do that. I think, I think that, that the, there's a capacity for duality there that both of those things can exist. So you can say, okay, parents, you want numbers. If I have them, I'm going to give them to you actually. And let's talk about the other things that sit below those numbers. So, so what are the keys there? I think, I think you nailed it. I think both things can exist at the same time as you can do numbers and also counsel them based on the underlying issues. So next step in communicating findings is humility. So say what you know, and don't say what you don't know. And I would say, especially in medicine in 2022, where paternalism is going away, which I think is good, that, that the humble physician tends to generate more trust, I think, I hope. Next one, balance if you feel like you can. So studies have said, if you, if you, if you have the ability to talk about the negative and the positive, just talk about both. So don't let negative certainty dominate your voice because we usually don't have negative, negative certainty that's supported by evidence. So in traumatic brain injury, this is what I say. I say, I don't know. If they're not following commands, especially I say, I don't know. And neither does anybody else. No, I don't say that. That would be horrible. I don't say that. What I often do say that in a really large hospital where I, where we try to communicate as much as we can, but there are so many people coming in out of that room and we do a lot of team communication is you will hear many varying opinions. Now we've worked as a hospital to say, okay, prognostication comes from one team or one unified voice. And we, that has changed a lot at this hospital in the last five or so years, but I still do share this. You will hear many varying opinions. Here's the one I give you based on evidence. Here's a comment from Jeffrey England, by the way, parents and families are scared. I agree. And what many people want is someone to walk them, walk the path with them throughout recovery. I think you worded that perfectly. And I agree with you completely. And that is really what it, that they're not necessarily, they're looking for an anchor or something to grab on. And sometimes prognostication is that anchor, but it doesn't have to be. And even somebody coming in here and saying, I don't know, but I'm with you probably has more value than I'm going to give you this information. Goodbye. All right. So here's my phrase. So for TBI, and I do say this similarly, I mean, you have to improvise, right? This is jazz, but medicine is jazz. So you do, you, you, you feel your room and talk that way, right? So in general, we don't have any evidence to predict the outcome in this situation. We can't even guess. Well, we'll have some information at four weeks, more at eight weeks, earlier estimates are not supported well with evidence asterisk, unless they're following commands. So I've seen some children in this situation do very well and some do quite poorly. So there's balance. Spinal cord injury, totally different situation. There are numbers available to predict what percentage of people will walk with a similar exam to yours. This is not a percentage for you because you'll either walk or you won't. Do you want those numbers? I get a lot more yeses than nos. So in this case, we don't have to wonder if a family wants numbers or, you know, look at that 82% of families want numbers or whatever that number is. We can just ask people, do you want the number? And I had about like 30 straight families say, we want the numbers. And then a run of four that said, we don't want the number. What we get is what we get. It was really strange, but that happens. So you offer them that thing with the knowledge that we're, regardless of that, you know, if you're AIS grade A, that we will do the rehab the same way, which is go for the best outcome. So this is how you talk and here's Adam. So this is all Adam. This is real. So we're talking about now what happened in these outcomes and why I wasn't able to predict them. There's Adam with his craniectomy and his helmet shooting baskets. I did not recommend that. Okay. He's doing it. However, this is his recovery. Okay. So this is in terms of his functional recovery. This is where he is. So he didn't have his skull back on. He's out shooting hoops, certainly not in acute rehab anymore. If you remember what I said, remember that he had a left metacarpal fracture. Do you see the brace on his right hand? This is not long after his brain injury. I think it was probably about four months after his injury. He has a brace on his right hand against, again, I recommended against this, but he did it anyway. Some things I can't control. He broke his right hand playing soccer goalie at the foremost point. So that left hand healed from his injury. That's a right hand fracture. He's a straight A student in college right now. He's going to graduate pretty soon. He wants to fire me as his PM&R doc and I get it. I mean, he's like, no, I mean not fire me, fire me. He's like, well, why do I come here? I think that's what he said. So Glasgow outcome scale five or like 10 or whatever. He is the best case that I have through this talk by far. Bob's case, not so good. So at one year, he was working on walking with a walker with help, needed help for activities of daily living, speaking, but with notable cognitive impairment, eating some by mouth, he had gained a lot of weight. At two years, it was similar, but walked with more independence. Interestingly, that puts him in the Glasgow outcome scale four. Although I know that when speaking with his mother, she is not pleased with his outcome. And so that's interesting. The Glasgow outcome scale is an interesting predictor because it's crude. It doesn't necessarily pick up true things like humanity. Carl, C7 AISA, neuro and AIS exam unchanged in two years. I think that's pretty consistent with our prediction model. And then here's Ryan Shays here. This is he started out at AISB, I would guess. And I don't know. Here, just watch. Do you see that? So that looks to me like a 36 inch box jump. I'm not sure. I've watched this to try to figure it out. And having recently jumped on one of these boxes last week, just to see what it would feel like. This is a really high box. So I do like to paint both sides of the picture. And Ryan Shays here is the other side of the picture, clearly. And the prediction model would have suggested that this is a possible outcome. Now, he won't get back to football. I think we know that for a lot of reasons. But that is the other side of things. So pulling this all together for traumatic brain injury, I don't believe that we have a strong prognostication model during the first few weeks in those patients that fit this category of really, we're not sure. Post-traumatic amnesia is a strong predictor, but we have to wait for that information. You have to. Spinal cord injury, we do have strong numbers that predict ambulation. They play out clinically. They do well. I think that you all are smarter than a robot. I'll say that. We bring it all together. I think you're all smarter than a robot. And that there's a study to say you're at least as smart as Johnny Five, at least as smart. And then also in spinal cord injury, ambulation is a big topic early, but I'm preaching to the choir when I say that future goals might be a bit different. This is what my family looks like because there's got to be a last slide for questions. Everybody's grown older since then, including that one jumping, that boy there who is just as teenager as they come. This is a chance for us to talk. If you want to raise your hand and say things that we'd love to hear from you, that would be great. Or ask questions in the chat window or provide comments in the chat window. Please join. Oh, yeah. Contact info. Here, ready? I'm going to drop it in the, there was a direct message about providing my contact info. So I'm going to provide that right now. That'll be my email. Oh, there we go. Please reach out if you want to collaborate. There's my email. Thanks, Hannah, for coming. Hannah is easy. So question from Emily. I can only see the most of your name. Emily Kivlehan, MD here. So any prognostic data for patients who are in prolonged disorders of consciousness? I went digging and that's tough. What would be the factor to say you're going to emerge from a DOC situation? And there's a researcher here by the name of Christy Katerba who is looking into that, or at least we've talked about it before to say, okay, how do we separate out those ones that will come out of prolonged DOC versus those that will versus those that won't? I think what that remains is a research question without a I'm going to hang my hat on it sort of answer. But also if you are interested in studying that, I can connect you to a person with a data set or the beginnings of a data set, a pediatric data set, or I would say a prognostic, or excuse me, I say the word prognosis so often, but a prospective study. So if you're interested, drop me an email. It's there. Good question. I will also throw in the fact that this is pure self-promotion. So here it is. I love talking about this, big groups, small groups. I enjoy it as a topic. I enjoy it because I learn a lot. And if you're an institution that you have a set of an audience that would like to hear it, I'm happy to share it. So yeah, I love doing it. So that's a self-promotion thing. So here's a broad question from Samantha. What is some current research in the physiatry field that you are most excited about? Okay. All right. So that question, I'm going to do my own part of that question, but I think also I want you all to throw it in the chat. Please tell me what you guys are excited about too. So that's a really interesting one. What am I most excited about right now? So I personally am excited about humanity and about human interaction and that aspect of what we do in medicine. So less about tech and directly improving outcomes with like interventions as much as making what we do into a better art. So the physician aspect, especially because so much of PM&R is here, here's your tool. We have the tools we can give them, but when you're going to do what we do really well, it's my opinion that you do it through your communication with humans. So it's not actually your hands that often. So I'm most excited about the humanities research in PM&R. I'm excited about medical narratives and the things coming out with medical narratives and those studies that I talked about closer to the end about the physician family interaction. But I'd love to hear what other people are interested in too. A comment here from Elizabeth Moberg-Wolf about neuro-using EEG a lot. Yeah, I agree with you that I don't feel like it's very predictive and I don't really know what to do with it. And I have some friends here that are EEG geeks and we hang out occasionally outside of work and I've challenged them with that same thing. I'm like, all right, can I hang my head on anything EEG? And I've gotten from people that are like, EEG is the answer to all of that's problems. These are friends of mine. I feel like I'm giving a hard time, but that's where they are. I think they share that view. So when you research on TBI, did you find him? This is from Taryn Davis. When you research on TBI, did you find information on the impact of pharmacologic therapies like neurostimulants? That is out there in, I would say underpowered studies overall. I think everybody's going to go first at imantadine as it's not a neurostimulant, but as a drug to say, what does it do? Because the imantadine study was by Wolf. Wolf? It's Wolf, right? Yeah. With two Fs. I hope so. It was like the best design for what we do in PM&R research. But if you look back at that study in terms of the actual amount of function that was changed before the washout period, the ability to actually show functional changes really hard because the difference was a point or two on their scale, which is not a huge change in function. And so there is research on neurostimulants. There is research on imantadine, but is it heavily powered and says this is really going to actually change things? I'm not there yet. Some great positive notes from people. And then Scott Paul saying, what about using evoked potentials as possible outcome measures when a patient is sedated and still has this sort of consciousness? Well, I wonder what that would do. So you have the ability to get them and say, okay, what's connected through? I mean, it's going to be something that's through peripheral nerves. I feel like it's a bit, the overall thing is a little bit crude, so you could add it as a variable, but what does it mean there? I'm not sure how to answer that one. I feel like I'm struggling to understand how that would help. And I certainly haven't seen any studies about it. Oh, I hear a baby Dubon though. Hello, baby Dubon. Is that what I hear? I think I do. It's good, Mary. Hi, Mary and baby. Jennifer Pham here, a gold study. Oh, this is cool. Yeah. So Jennifer, it's a good question. So since the gold standard study, so the Walker 2010 was done in adults. With your experience, do you think that the post-traumatic amnesia of greater than eight weeks prediction is a lot wider for pediatrics patients? I can say yes. And if I can pull up a really quick picture for you that hopefully I can do it quickly. I'm going to stop screen sharing for one quick second, and then start again in one quick second, if I can find it on my computer here. Great question. And I have an answer for you that we know that outcomes are worse by age. And find the age talk, Nathan. You know, things are a problem when I'm speaking in third person. This is not good. There, age TBI slides. Got it. Okay. Share screen, age TBI slides. Cool. All right, here we go. Here's my best shot at your answer. So does age matter is the question. Is that the first slide? Go. So here's a study 5,600 patients. It was a pharmacologic study, and they basically stole the data. But they said patient age and outcome in severe brain injury, it's analysis of 5,600 patients. So does age matter in brain injury? Oh, yes, it does. So retrospective, they're all older than 14, but I think that we can apply this anyway. So primary outcome here is Glasgow outcome scale at six months. It's not ideal because it's not very long, but I think it's saying something. Look at these lines. So on your y-axis is probability of a poor outcome. And on your x-axis is age in years. And both mortality and unfavorable outcome, they are linear, and they go straight up. And they don't stop. So if you look at all the modeling for this, it just goes straight up. And so the probability of both mortality and unfavorable outcome goes up with age. And their conclusion, which is it's a data-based study, but their conclusion here, the odds ratio of a poor functional outcome per 10 years of age is 1.46. All right. So the odds of a poor outcome increased by 40 to 50 percent per 10 years of age. I am comfortable extrapolating that backwards for the 4 through 14 population to say they're going to do better than the 14 through 24. I'm not sure of that, but I think this is enough here to say two things. Number one, that I think kids do better than adults in that posttraumatic amnesia window is wider for kids in terms of getting a better outcome, number one. And then number two, for those of us that have collected gray hairs here, it's really scary getting older because every decade you get older that for every 10 years of age, your probability of a poor outcome is 40 to 50 percent higher. I mean, that's a really big number. Did that answer your question, Jennifer? Is that what you were looking to hear? Ah, yes. And fear of aging, too. I agree. Definitely. I wanted to jump in here and say thank you. I learned a lot. And I love the reminder to say what I know and don't say what I don't know. I will carry that motto throughout the rest of the week. And I wanted to thank you, Dr. Rosenberg, for this great talk. We've got lots of kudos in the chat. And as a reminder to everybody, I'll post this recording on the online learning portal within the next couple of days so you can claim your CME. And if you want to reach out to Dr. Rosenberg, he did share his contact information earlier. But if you didn't capture it, just contact education at aapmnr.org and I can put you back in touch. Yeah, please reach out. I'd love to hear from you guys. There's a question there from Powell. I'm going to hold off on answering it right now because of time. But Powell, would you mind sending me an email? Just click on that email in the chat window and send me one because I have a thought. It's a question about frustration with unrealistic expectations. But I would love to wax poetic about that topic. So if you just drop me an email and say hi and remind me what the question is, I would love to reach out. And I hope to meet you guys in person if we see each other around conferences, hopefully in person. Again, come by, introduce yourself. The names are lining up in here. And so hopefully we can add some faces to those names soon. All righty. Thanks, everybody. We'll see you for our next talk in May. All righty. Take good care. Bye-bye.

evidence-based outcome predictions

pediatric traumatic brain injury

spinal cord injury

predicting outcomes

post-traumatic amnesia

8 weeks

ASIA impairment scale

ambulation

numeric estimates

prognostication