Hello, everybody, and happy Friday. My name is Mark Ellen. I'm the session moderator for today's research spotlight on pediatric rehabilitation. I serve as the chair of the evidence committee, and it's my duty to inform you that this represents the best of the best of submissions, of over 700 submissions this year, painstakingly reviewed by other members within the AAPMNR, and judged to be the best. Thank you all for being here. We have a little housekeeping. Please turn off your microphones at home, if you will, and let me introduce the first speaker today. It's Hethal Patel, a PGY-4 at the University of Washington, who will be performing a spinal cord injury fellowship next year. She'll be discussing disparities in admission to pediatric and adult inpatient rehabilitation facilities among adolescents. Dr. Patel. Thank you. All right. So, sort of as was mentioned, my research addresses disparities seen in admission to pediatric and adult inpatient rehabilitation facilities, specifically among the adolescent population. I'd like to begin by thanking Dr. Barnett, who first initiated this project, and Dr. Fuentes and Dr. Bunnell for all their contributions as well. Next slide, please. So to provide some background, Harborview Medical Center is the only level one trauma center for both adults and children in the five-state WAMI region, which consists of Washington, Wyoming, Alaska, Montana, and Idaho. And our rehab medicine consult service provides guidance on post-traumatic rehabilitation for all ages. Adolescents, in contrast to younger children, may be admitted to inpatient rehab either at Harborview Medical Center or at Seattle Children's, but there's no formal process or guidelines for this determination, and outcomes for this population are unknown. This is the case both at our facilities and in the literature in general. The goal of this study was to better understand rehab services provided for adolescents, and some of our specific aims were to describe the overall characteristics of adolescents served by our rehab consult service, to evaluate and identify factors that are associated with admission to inpatient rehab at our peds and adult facilities, and to compare rehab outcomes of adolescents at these two facilities. In order to accomplish this, we performed a retrospective chart review of all adolescent patients between the ages of 15 and 18 who received a rehab medicine consult between 2017 and 2019. We further collected their demographic data, medical information, and information on their overall rehab course. Next slide, please. There were a total of 96 unique patients in this study, and in regards to their patient demographics, most of the patients were male. There was a wide geographic distribution of patients, 42% were living in King County, which is a county Seattle is located in, 40% were in other Washington counties, and 11% were in the surrounding WAMI region that I mentioned. Compared to general Washington state demographics for this age group, our study had black adolescents that were overrepresented and white adolescents that were underrepresented. The most common primary injuries were TBI and SCI, traumatic brain injury and spinal cord injury. MBCs accounted for 41% of injuries, and violence-related injuries accounted for 19%. There were significant disparities in the etiology of injury as well. Black and Hispanic patients were more likely to experience violence as the cause of their injury compared to white patients, and patients with Medicaid were also more likely to have violence-related cause of injury compared to patients with private insurance. Overall, 46% of patients were discharged from acute care to inpatient rehab, and an equal number were discharged directly home. Discharge to nursing or LTAC facilities was quite rare. Comparing our facilities, adolescents were more likely to remain per review for inpatient rehab compared with Seattle Children's if they were black compared to white, if they had Medicaid compared to private insurance, if they had violent-related injury compared to other etiologies, and if they had a spinal cord injury compared to other primary diagnoses. We were not able to determine the independence of these associations because of sample size and correlation between race, insurance, and etiology of injury. Regarding outcomes, there was no difference in discharge location after inpatient rehab or transfers off the rehab unit. FIM change and FIM efficiency were not different between facilities. However, length of stay was significantly longer at Seattle Children's compared to Harborview when adjusting for the diagnosis. Next slide, please. We have several preliminary conclusions from this study. The further investigation is needed both within our system and more broadly. First, significant disparities were identified in the incidence of injury and rehabilitation care of adolescents. Adolescents experiencing systemic disadvantage, including racism and low socioeconomic status, were more likely to be injured by violence compared to their peers and were more likely to remain at Harborview for inpatient rehab compared to transferring to Seattle Children's. Second, the most common diagnosis in our study were traumatic brain injury and spinal cord injury. There were a difference between these populations in multiple areas, including SEI patients more likely to require IPR and remain at Harborview Medical Center compared to TBI counterparts. Finally, the outcomes at Harborview and Seattle Children's were similar with no differences between FIM change or FIM efficiency, but as previously mentioned, the length of stay was longer at Seattle Children's when adjusted for diagnosis. There were several limitations to this study. This was a relatively small sample size, single system, and retrospective study. Therefore, our conclusions are preliminary and may not generalize to other systems. Given the limitation of this study, further investigation is needed. Additionally, we think that these results could lead to interventions and referral and admission screening process for adolescents overall. So hopefully we'll see more of that to come in the future. Thank you all for your time. Feel free to check out my poster in the gallery, and then you can also send me a message if you have another question for me, or you can wait until the end when we do the final Q&A. Thank you. Thank you, Dr. Patel. Well done. Our next presenter is Dr. Edward Dabrowski. He's an associate professor at Oakland University and serves as a systems chief at William Beaumont. His talk is on efficacy and safety of incobotulinum toxin A for upper or combined upper and lower limbs spasticity in children and adolescents with cerebral palsy. The results of the phase threes are a study. Well, thank you very much, Dr. Ellen. I appreciate being here, and I appreciate the folks coming in to listen to this. I think that the objective of the study was really to assess the efficacy and safety of incobotulinum toxin A in upper and combined upper and lower limbs spasticity in ambulant and non-ambulant children and adolescents with cerebral palsy. I think that, as we all know, spasticity is a huge problem and is the most common movement disorder in patients with cerebral palsy. Just as a little background, for those who may not know, incobotulinum toxin A is also known as Zeamin. It is produced by MERS Pharmaceuticals out of Frankfurt, Germany, and that it is a 150 kilodalton molecule because it lacks complexing proteins, and it is approved by the FDA for upper limb spasticity in children between the ages of 2 and 17. But interestingly enough, the label must say not for cerebral palsy, and that's sort of a curveball here because this whole study involved 350 patients who were all kids with cerebral palsy. That has to do with orphan drug status and specifically both Allergan and Ibsen own rights to upper and lower limb designations in CP. The design was a randomized Phase III study with a double-blind main period and an open label extension period. By the way, there's no way I can get through in seven minutes this entire poster, so I will refer you to the article in Pediatric Neurology that we published about the entire results in May of this year. Participants were 2 to 17 years of age with unilateral bilateral CP and an Ashworth scale of greater or equal to 2 in the main clinical target patterns. That is to say you had to choose a flexed elbow or a flexed wrist as your pattern of choice that you then would direct your attentions towards that and everything else beyond that depending upon what the protocol allowed. And remember, the Ashworth scale is a 0 to 4 scale, 4 being rigidity, 0 being no rigidity whatsoever. What was nice about this study was that it included all GMFC classes, 1 through 5, and upwards of 30% of all of the children that were involved in the study were GMFC 5s. Interventions included in the main period, the patients were randomized to a 2 to 1 to 3-incobotulinum dose groups including 8, 6, and 2 units per kilo body weight with a maximum of 200, 150, and 50 upper units in the upper limb with additional lower limb injections that were total dose less than 16 to 20 units per kilo per body weight or 400 to 500 units depending upon the gross or scale. I'll refer you to the method section, the second column. If you look down with little bodies, both D and E, I believe, talk about GMFC classes 4 and 5, and you can then see the difference in 1 to 3 and 4 and 5, the difference in dose allotment. In the 1 to 3, a total body dose of 500 units or 20 units per kilo was allowed, whichever was less, whereas in the 4 and 5s, it was 16 units per kilo or 400 units total. Patients received three further injection cycles in the OLEC study with doses per 8 units per kilo per body weight, so all the three that were done in the main pattern group were shifted to 8 units per kilo thereafter. Our outcomes included the Ashworth, which I've already mentioned, the global impression of change scale, which is a 7-point Likert scale, essentially, from minus 3 to 3, 3 being much improved and minus 3 being much worse, and, of course, adverse events had to be recorded. The results, we had 350 patients starting off this study, 62% were male, the age was roughly 7.3 years of age, as I mentioned, 30% of them were GMFC class 4 and 5, and another 281 of that 350 completed all four cycles into the OLEC, through the OLEC subperiod. Ashworth scores for the upper limb main clinical pattern improved significantly from baseline to week 4, with a significantly greater improvement in the 8-unit per kilo group versus a 2-unit per kilo dose group. Improvements were observed in all treatment upper and lower clinical patterns and across the OLECs. The GICS scores confirmed global improvements in upper and lower spasticity, but that did not differ between dose groups. There was no increased incidence of AEs with increasing dose or repeated treatment. Conclusions, the data provide us evidence for sustained efficacy and safety of a multi-pattern incubotulinum A treatment of spasticity in patients with CP across all GMFC categories. AEs were not dose-related and did not increase with treatment cycles. Thank you. Thanks, Dr. Dabrowski, interesting stuff. Our next speaker is Devin Kennedy. He is a pre-medical student applying to medical school, currently working at Gillette's Children Specialty Healthcare. He's going to speak to us about leg-length discrepancy in children with hemiplegic cerebral palsy and changes with growth print. Awesome. Thank you so much. Yeah, so today I'll be presenting leg-length discrepancy in children with hemiplegic cerebral palsy and changes with growth print. And I'd just like to thank Dr. Supreet Deshpande and Dr. Mark Cornley for collaborating with me. So hemiplegic cerebral palsy is one of the most common congenital disorders in children. It's commonly held that children with hemiplegic cerebral palsy often have a leg-length discrepancy. With that, of the involved side tending to be shorter than that of the uninvolved side. To our knowledge, a conclusive study has not been conducted to verify this. And thus, our objectives of this study were to, one, evaluate the leg lengths in children with hemiplegic cerebral palsy, two, determine if there is a significant leg-length discrepancy, and three, if present, how the discrepancy changes over time as the child grows older. This study was a retrospective chart review at a large pediatric rehabilitation hospital, Gillette Children's Hospital. Our study initially included about 250 patients, children with hemiplegic cerebral palsy, which was then whittled down to about 51 children with hemiplegic cerebral palsy, based off of two criteria. The first of these criteria, they had to have a scanogram or an X-ray beyond the age of five or after the age of five. And secondly, patients could not have any invasive surgeries performed on their lower extremities prior to the X-ray or scanogram. So bilateral leg lengths in centimeters of all patients were then collected through these scanograms, which were taken supine, and X-rays, which were taken standing up. We then made leg-length comparisons, and as they changed over time, we made comparisons as well between their first and last patient scanograms. The difference in leg length in centimeters was calculated, as well as the percentage of difference in leg lengths, and we used a matched paired t-test to evaluate whether or not this LLD was significant and proportionally significant as well. Of the 51 patients that met the inclusion criteria that I just mentioned, 36 of them had serial scanograms in which we could use to track as they grew older and changes over time. And our results found that the involved side was significantly shorter than that of the uninvolved side by an average of 1.329 centimeters. And focusing in on those patients that had serial scanograms, we found that between their first and last patient scanograms, the leg length discrepancy increased by, on average, 0.72 centimeters between the first and last scanogram. Interestingly, we found, however, when taking into account proportionality, this LLD between the first and last scanogram showed no significant changes, it tended to remain the same. So concluding with our results, we found that there was an LLD in children with hemiplegic cerebral palsy, with that of the involved side, again, being significantly shorter than that of the uninvolved side. The LLD increases over time in centimeters as the patient grows, but the percentage of difference in leg lengths tends to stay the same as the child grows older. To our knowledge, this is the first study that shows this proportional, that the proportion of LLD tends to remain the same across time. We hope that physicians will take into account these findings when considering treatment options for patients with hemiplegic cerebral palsy. And moving forward, we would hope to include more patients in this study to solidify our findings further. Thank you. Hey, Devin, really, really nice job. Thanks for bringing it here. It was really good. All right. Our next presenter is Catherine Stephanie. She is a PGY-1 at Cincinnati Children's Hospital, and she'll be discussing school liaison programming and pediatric rehabilitation, Dr. Stefani. Oh, Stephanie, sorry. I just need the ability to share my screen, which I'll do right now. And I'll make this bigger. All right. Well, hello, everyone. Thank you for having me. And I would also like to thank the other co-authors on this descriptive study at the Riley Hospital for Children's School Program. It has been really educational for me as a resident working with the school hospital school program and seeing kind of all the diversity things that they do, which definitely prompted my interest in this study, which I'm excited to tell you about. So the Riley Hospital for Children's School Program is a grant-funded initiative. And I think that's interesting and important because not all of our hospital schools are grant-funded. Some of them are part of the public school system, and some of them are private funded. And this hospital school program, I specifically looked at children that were on our inpatient rehabilitation service. And medical conditions often treated there are related to corresponding cognitive impairments. So specifically, traumatic and non-traumatic brain dysfunctions were the top two diagnoses of our patient population at Riley Hospital. And given the high level of cognitive impairment in this population and the fact that this is school-aged children, it's very important to have liaison services available to consider both a patient's new cognitive level as well as what services they will need to return back to school. So the objective of our study was to identify what needs students had as well as the needs that the school liaison program provided for these children. Our study is a single-site retrospective review of de-identified data that was primarily collected for grant funding purposes, but throughout the last couple of years has been expanded for more of these more descriptive investigations. In my study, I looked at patient demographics, educational characteristics of the patients on the rehab unit at admission. I looked at each of the students' schools and actually individually researched the schools to find out whether they were public or private, et cetera. And then I also looked at the rehabilitation activities during the admission and then what needs were identified for discharge. My major outcome measures were the prevalence of school accommodations at discharge, the academic accommodations required at discharge, such as an IEP 504 plan, the average number of days that they were seen by the hospital school program, and the number of tutoring sessions that were provided. Now I'll just direct your attention to the middle of my screen here, which shows in the box that shows that's titled RH CSP services. It delineates what services are provided at rehab as well as the liaison services. So briefly, rehab services are considered those provided directly to patients by the school liaison teacher. So that can be tutoring in the inpatient unit, that can be assessments for what is their new cognitive level, as well as conferencing with the rehab team to identify school needs. Liaison services are a little bit different, and I found this to be very interesting, especially at Riley. The liaison services, some of them involve what's called a reintegration meeting where teachers meet directly with the schools, case conferences where if a student is identified to need a new 504 IEP plan, accommodations are created. And then outreach was especially interesting, and that actually involved the school liaison teacher going to the school and actually providing education on conditions for the actual classroom or other members of staff at the school. As you can see in the pie chart for our results, just demographically, our study included 482 unique patients, and it was a pretty even split male to female. And as you can see, the majority of our patients were white with a smaller proportion of children of color. The majority of our patients under the results here you can see attended brick and mortar schools, but they could be public or private, and there was a pretty good split with urban and rural. Most of the patients on the inpatient unit were participating in a regular or a modified curriculum and had a low rate of 504 plans, but a higher rate of IEP plans upon admission. And then just briefly looking at explaining across what services all patients admitted to the inpatient rehab center received some type of tutoring service or assessment, and the vast majority throughout their hospitalization needed a reintegration meeting. 16.2% received a case conference, and less than 1% received one of those more intensive outreach visits that I described where the teacher would actually go physically to the school. Also of note, patients were seen for about 9.4 school sessions on average over an average of about 14 and a half admission days. And then finally, some of our key findings here with regards to educational characteristics at discharge, which is that 0% of patients required medical withdrawal from school. 12.4 required a homebound service due to school services due to their medical status, and there was a high rate of academic accommodations needed in order for these students to reenter school. And then before talking about my conclusions and limitations, I'll just direct your attention to the bar graph at the bottom, which I will try to zoom in here a little bit for you, which does show a distribution of our patients across different grades with asterisks, stars in purple and red to indicate grades when significant transitions occur in high stakes testing. So we can see for the patients in 1st, 3rd, 6th, and so forth, that they really were experiencing with their admission to the inpatient rehab unit, most likely a significant life changing event that would really change, potentially has the potential to change their academic trajectory. And so in conclusion, the pediatric rehab patient population here at Riley that was studied had a high rate of academic difficulty even at admission, and the needs appeared to increase in response to their medical condition. And as a result, 57.1% of patients required a 504 IEP plan at time of discharge. And so I think the things that are important is that this population needs continuous skills school liaison services to support existing and often very escalating needs. I think there were clear limitations of our study, and that is a descriptive study of a limited population, but I think Riley being a very large school program does shed some interesting light. And I believe that future research should look into whether intensive rehab school related services such as these make impacts in the long term trajectory for these patients. Thank you very much. Super job, Dr. Stephanie, really well done. Thank you. Our next presenter will be Dr. Jill Milan. She is the Medical Director of Pediatric Rehab at the Marshfield Clinic. Dr. Milan. Hi, everyone. I am coming to you from northern Wisconsin where the temperature is 37 degrees and it's supposed to snow within the hour. So I do not see my slides. Here we come. All right. So I am honored to present to you today this research study on telehealth versus in-person visits for neurodevelopmental follow-up of premature infants, a prospective study. Next slide, please. So this was a pre-COVID prospective study designed primarily to see if telehealth visits would decrease no-shows when compared to in-person visits. Even though the risk of neurodevelopmental disorders is higher in premature infants and early detection is recommended, follow-up visits are often not scheduled or attended. In our clinic, about 20% of families with babies born at less than or equal to 32 weeks estimated gestational age did not schedule the recommended follow-up visit. And about one-third of those who did schedule did not attend. This is consistent with reports across the United States and Canada over the last 15 years. The literature reviewed pointed to distance from the family's homes to the neurodevelopmental follow-up clinic as the primary reason for not scheduling or attending in two-thirds to three-fourths of the families interviewed. Our health system has been fortunate enough to have a telemedicine system in place since 2009. This is because we have a catchment area of 30,000 square miles. So hopefully you can see my arrow here. So this is Marshfield, if you don't know Wisconsin. This is Marshfield in the center, Madison is down here, Milwaukee, our biggest city is way over there, the twin cities of Minneapolis and St. Paul are here, and Duluth is up here. So we cover really pretty much all of this area plus the upper peninsula of Michigan, which is there. Because of this telemedicine capability, we were able to study if decreasing the distance the family had to travel increased attendance. So upon hospital discharge, the families were offered the option of telehealth or clinic follow-up with a neurodevelopmental specialist, either myself or Dr. Mei Zhang, a pediatric neurologist. We recorded the distance from their home to the central clinic. We decided on a standardized neurologic exam, and a form with this exam was filled out by the physician with a yes or no box behind each element, and we were to check if we were able to do that element or not able to do that element. We have telehealth RNs that were trained in a training session in person, and those who couldn't make that could review the recorded video. A three-item satisfaction survey was given to parents at their appointment with an addressed and stamped envelope so they could answer their satisfaction questions anonymously. A barrier survey was sent to parents who declined follow-up or no-showed. All this was recorded in a REDCap database without any PHI. As we found out, the distance from the central clinic did make a difference. For the people who selected in-person clinic visits, the median distance was 35 miles. For those who selected telehealth, the median distance was 63 miles. Next slide, please. So here's a little more detail of the data. So in the upper left, we show that the estimated gestational age was similar between those who chose in-clinic visits and those who chose telehealth visits without any significant difference. The physician survey results showed that really, tendon reflexes were the only thing or the main thing that people had some trouble performing regularly. And then in the lower left, we showed that the number who chose a clinic visit was 26, a telehealth visit was 14. This was out of a total of 50. That only adds up to 40 because 10 said they didn't need a follow-up. Under no-shows, 100% of the telehealth visits were attended, but 8 of the in-person visits did not show up for a 31% no-show rate. So again, 20% didn't schedule, 31% didn't follow up for in-person visits, which is consistent with our pre-study evaluation. The questionnaire basically asked if the parent was satisfied with the visit, if their concerns were addressed, and if they felt the physical exam met their standards. Next slide, please. So this is my poster. And in summary, telehealth follow-up of premature infants decreased no-shows with good parent and physician satisfaction. This was a prospective study, self-selected visits in clinic or telehealth. The main hypotheses were that telehealth would decrease no-shows and that distance would affect choice. Satisfaction of parents and physicians were assessed in a barrier survey to find out why parents declined their follow-up visits was given. In the upper left, you can see that of the 50 eligible babies over this one-year period, 26 selected in clinic, 14 selected telehealth. There was a 31% no-show rate for the in-person visits and a 0% no-show rate for the telehealth visits. Distance made a difference with the people selecting clinic much closer to the clinic than those who selected telehealth. Parent satisfaction was high, and the only complaints were actually in the in-clinic visits. Physician satisfaction was also high, with the only difficulty in assessing reflexes. You know that's hard even for physicians in person, and some of the RNs just couldn't make it work. And in the barrier survey, we found out that parents who didn't see any problems with their babies but also had a lot of faith in their primary care physicians were more likely to decline a follow-up visit. Thank you very much. Thank you, Dr. Milan. Really well done. Okay. I think this is going to be part of our future, is going to be telehealth. We've had a bunch of talks on this in the last couple of days. One other housekeeping thing. Please hold all your questions in the chat box until all our speakers are done. We have a couple more to go. Thank you. We're back to Dr. Dabrowski from Beaumont Healthcare, who's going to discuss now goal attainment following treatment with ABO botulinum toxin A and intensive home therapy in children with upper limbs spasticity. I'm sorry you have to put up with me again, but in any event, I just want to first start off by thanking Dr. Ellen, and then I also want to thank my colleagues who are part of this endeavor. I'm actually substituting for Dr. Jorg Carenza del Rio, and unfortunately he could not be here today. So let me just take a step back and say, we know that in children with upper limbs spasticity, botulinum toxin injections are often used to produce a selective reduction in muscle tone while optimizing the potential for therapies to enhance their skills. Now, we've recently published the main primary endpoint analysis of this phase 3 study, which in developmental medicine and childhood disorders, where the primary data confirmed ABO botulinum toxin, which is dysport, at 8 units per kilo and 16 units per kilo significantly reduced hypertonia versus the 2 unit per kilo low-dose group. In this presentation, we look at more detail at the effect of treatment on goal achievements. Briefly, this was a double-blind repeat cycle study. During cycle 1, children 2 to 17 with CP and spasticity of greater or equal to 1 in the modified Ashworth scale were randomized to receive ABO botulinum toxin at doses at 2 units per kilo, 8 units per kilo, and 16 units per kilo. In the elbow or wrist flexors and other upper limb muscles, followed by an intensive individualized home exercise therapy program. Goals were chosen at baseline, and goal attainment was assessed at 6 and 16 weeks using the goal attainment scale. For those of you who may not be familiar with the GAS, it is a scale that essentially goes from minus 2 to plus 2, showing less than expected, or much less than expected, to much more than expected results. It's a very nice thing that we actually use in our clinics as a standard. In table 1, we can see active rather than passive goals were more commonly selected for this population of children. The most common goal that was selected was to involve, the parents would have liked, or the child would have liked to see more involvement of the affected arm more in daily activities. So, you can take a look at this table and see the active functions include grasp and release, use of the limb, reaching, etc., versus more passive function, such as dressing where the caregiver is helping, it's easier to dress the child, or donning and doffing splints, hygiene, more along those lines. In figure 1, we can see that during the first treatment cycle, all groups of children attain their goals at least as expected, and this was evidenced by the GAS T-score being at least 50. We can observe that the goal attainment improved from 6 to 16 weeks, perhaps indicating a time lag from the peak of ABO botulinum toxin effect on hypertonia to goal attainment, which may be expected as children, as their tone drops, they're beginning to learn to complete the tasks with reduced spasticity. In figure 2, we can see that a high proportion of children achieved their primary goals, to quickly, and it's actually quite impressive, as this was across each of the treatment groups. So, to quickly summarize, treatment with ABO botulinum toxin A, or Dysport, plus an intensive home therapy program was associated with high levels of goal achievement. In this population of children with cerebral palsy, active goals were more commonly selected than passive goals. The GAS responder rates were generally higher at week 16, indicating a time lag from peak effect on hypertonia to goal attainment, which may be expected as children, again, learn to complete tasks with reduced spasticity. Of note, goals were achieved as expected or better, regardless of treatment groups, perhaps suggesting that the intensive home exercise therapy, which comprised, by the way, exercises specifically directed towards the support and to support the individual goal that was picked out by the parent or the child, was an important factor in goal achievement. And I thank you very much. Thanks, Dr. Dabrowski. Really well done again. Getting two submitted that got in. That's fantastic. Our last speaker today is Heather K. Vincent. She is an associate professor at the University of Florida and runs the lab there. Dr. Vincent, thanks for coming. It's all yours. Thank you so much. I appreciate it, Dr. Allen. All right. Well, thank you everybody for joining me today. I'm hoping my voice is going to hold out a little bit. I'm excited to share with you some of our preliminary outcomes from a research project that we've been working on now for the last couple of years. We have spent some time really trying to understand a very understudied population, children with juvenile idiopathic arthritis. What makes these children very unique is that they are born with arthritis and then move from childhood into adulthood with this disease. And so trying to understand their physical function and which metrics of how they move are most sensitive to treatment interventions are going to be of utmost importance. So over the last couple of years, in our systematic reviews and pilot work, we recognize that we really have a very poor understanding of the gait mechanics of walking and related physical function in these children. And despite the growing number of treatments to help with the symptoms of juvenile arthritis, these children continue to have persistent functional limitations and also have flares of poor function of life as the disease flares up and down throughout childhood. Another big challenge is that for children, one of the key aspects of a high quality of life is physical function and participation in sport and activity with other children. These metrics are very rarely ever measured in the clinical paradigm. And so what we set out to do is determine if we can first determine what those functional differences actually are among children with and without JIA, then we can use those to set our specific interventions and apply those metrics to determine what is actually working and making the best difference in the lives of these children and their families. And so we used a comparative observational study approach and we enrolled children with arthritis in various stages, some who were in flares and who are without. They are going to be returning to the lab when their condition either worsens or gets better. So we have reflections of both states of the disease. Our healthy children were age-matched controls and the children who had arthritis also had various subgroups. So we're trying to really get a true reflection of the general population here, seven to 21 years of age. And so these children were brought in and they performed a 3D motion analysis of gait at self-selected and fastest tolerable speeds. And we also used force plates to determine postural sway. So getting some objective measures in different postural permutations, such as a two foot stance, a dominant single leg stance, and a tandem stance. We also applied some functional metrics that are commonly used in adults to see if these might also be valid in this population. And so we use the number of repetitions of chair rises to be accomplished in 30 seconds. We use the stair ascent and descent and collected Wong-Baker of the face scale pain measurements after each test. We also involved the parents where appropriate when children completed the promise measures on pain interference, physical function, mobility, and global health. To get a sense of what their physical activity levels were and participation in sport, we had them engaged in the pediatric functional activity breed scale or the PEDIFABs. So we applied analysis of variance and Mann-Whitney test for a variety of analysis to determine the differences between these two groups. And so table one provides for us information showing that they were actually pretty well matched for general characteristics with respect to age, body mass index, percent female, and close to ethnicity and race. If we look at the promise scores for global health and physical function, when put all together, the children with JIA tended to have lower scores. But when we separated out kids with flares and not in flare states, the kids with flares had significantly worse scores compared to the healthy controls. For all children with JIA, promise pain interference scores were significantly higher, and that value continued to worsen if a flare state was present. Similar with the PEDIFAB scores, children with arthritis tended to be less active than their healthy control counterparts, and those that were in a flare state almost had no extra physical activity at this time. If we look at the functional test score results in table two, I just want to draw your attention to the fact that if we look at the chair rise performance, stair climb, and the gait speeds, either at self-selected or fast, all of the performance metrics were significantly lower in the children with JIA. Two of the most discriminating tests for kids with flares and those without were the stair descent time with the sheer stress, particularly over the painful knee joint, as well as gait speed showed even further separation of performance among children with JIA. If I can draw your attention to the right side of the poster, if we look at some of the temporal spatial parameters of walking gait, children with JIA had shorter step length, lower center of gravity vertical displacement or less bounce, and had a lower cadence than healthy children at self-selected speed. When forced to go at a faster speed, the children with JIA could match the metrics of those healthy controls, but they didn't want to do that, so even at self-selected speed, that speed was actually slower. Figure one gives us the ground reaction curve comparison during walking gait, and what this shows us is the healthy control in the blue line and the children with JIA in the red line. The force is represented along the y-axis and the gait cycle time is represented along the x. And what I'd like to show you here is that children with arthritis achieved lower peak ground reaction values and lower loading rates, which basically comprises a very cautious gait. And then finally, when we look at postural stability and the amount of sway in each direction while standing on the force plates on the floor, there were some variable measures here without a whole lot of consistency between children with and without arthritis. In fact, some of the measures depending on the direction of the sway were actually better in children with arthritis than those without. So what do these data tell us at this point? As we continue to accumulate more children in with arthritis at various stages of the disease, what these are showing us is that children with JIA really show poor both subjective and subjective scores, particularly in areas of mobility and body weight transfer, but potentially less on postural control, at least in a stable position. So we're looking forward now in our phase two of applying these metrics to determine which treatment paradigms are more effective for allowing these children to lead a more fulfilled and functional life. Thank you so much. Thanks, Dr. Benson. That's really important work and can't wait to see phase two. So that concludes our speakers for today. Let's give them a good virtual round of applause. And now we can have time for questions. And we go back to an initial question for Dr. Patel. Did the location of acute hospitalization, i.e. acute care versus pediatric acute care, play a role in inpatient rehabilitation versus PEDS inpatient rehabilitation? Or were you only looking at, sorry, adolescent SCI patients coming from adult acute care? Right. Am I unmuted? Yes, I am. You're fine. That's a good question. So our consult service ends up seeing all patients of all ages, whether they're in the pediatric acute care or adult acute care. So I don't think that should have played a big role. We just took the age group regardless of what location they're at. But typically in our hospital, they would be more on the PEDS acute side given their age. Excellent. And Dr. Stephanie, how does the demographic represented in the study of yours compare to your general demographic composition? Yeah, that's a wonderful question. It's very similar to the major Indianapolis region, I would say, which is about 60% Caucasian and then anywhere from like 10% or so, depending on what region, Black and then other minorities after that. And I think the other piece that I will say that we are looking into with this study that we are doing some chart digging on is some markers of socioeconomic status with the limited information that we have. And one of the ways that I'm working to do that is to identify schools that have a large percentage of students that receive free or reduced lunch as a marker of socioeconomic status. So that'll be part of a subsequent analysis reported in our paper for publication. But thank you for the question. Excellent. Excellent. And Dr. Hurwitz has a question for Devin Kennedy. What percent of patients had an LLD? Do we know how much more that that is than the non-CP population? Welcome to the fire, man. Yeah. So we found that the involved side was shorter than the uninvolved side in 42 of the 51 patients. Yeah, 42 of the 51 patients. And then only really a few were outliers where there was no difference that we found in what else did you ask? Yeah. And I don't know. It's a good question. I don't think we've compared that percentage, the 42 out of 51 to the non-CP population, but that's a really good question. Excellent. Excellent. Thank you. So I think Dr. Kim's question is for Dr. Dabrowski. Did all patients have botulinum toxin injections and or phenol injections regularly or no spasticity managements were done? It will be different if they had intense spasticity management. So Dr. Kim, I think that's for Dr. D. So prior, there was a restriction in all of the studies that you could not have had a phenol or an alcohol block upwards of six months prior in any muscle. So that would be an exclusion criteria. Oh, Dr. Kim's question was for Devin Kennedy. Devin, did you guys use any blocks on your patients in the leg length discrepancy? Oh, sorry. I was muted there. It's much easier in real life. Let's see. Let me read. Sorry. Um, no, I think, I think we, um, what we, what part of the study was, was we were trying to, um, monitor whether or not, um, they, they received these injections. Um, and we had, we, we were trying to do, uh, two different studies with and without, um, these injections. Uh, but we just didn't have enough, um, patients, a part of the study to get really significant results. Um, so I, I think we included, we ended up including, um, the, the, the patients that did have, uh, injections like these. Okay. Thanks Devin. Well done. Any other questions for our fine faculty today and presenters? Well, again, thank you all for attending. These were the best of the best of the pediatric, uh, rehabilitation, uh, submissions out of over 700 submissions, uh, total and peer reviewed, uh, by your peers here in the AAPMNR. And these are the top seven that came out. Uh, thank you all for being here and thank you to all our presenters for today. Good job. We look forward to seeing you next year in Baltimore. Thank you. Thank you. Bye now.

disparities

admission

pediatric

adult

inpatient rehabilitation

adolescents

rehab services

outcomes

systemic disadvantage