Hello, everybody, welcome to our presentation today. It's Top Papers in Pediatric Rehabilitation, I'm Matt McLaughlin, I'm an assistant professor at Children's Mercy Hospital in Kansas City, Missouri, and I have the distinct pleasure today to be joined by Dr. Mary Dubon and Dr. Sruthi Thomas, who will also be doing their presentation to follow mine. So as many of you know, we've done this presentation numerous years in a row now. And the methods that we use, I think, are paramount to the success of this presentation. And as you know, that we spend lots of time starting in July 1, essentially reviewing all of the articles from the prior year. So that essentially goes from July 1, 2019 to June 30, 2020. We look through top pediatric and PM&R journals and cross-reference that with specific topics within PubMed. We have a real emphasis on looking at original research articles, but we don't really look so much at systematic reviews. We occasionally include some consensus statements, but for the most part, what we're really looking at is what are the top new papers that are originally published research articles. We read all of the abstracts that we go through. Both Mary and Sruthi were very exuberant in their abstract preparation and selections this year. And I believe we ended up with over 125 abstracts that we reviewed. And we ordinarily ranked those on a scale of 1 to 5, essentially 5 being the best score, 1 being a score that we thought was not as good. Once we did that, we re-ranked and eliminated articles to decrease the number down to the actual 10 articles that we're going to be presenting today. As you know, I love stats. So this is the math stats portion of this presentation. And I always like to see how we all do whenever we are ranking these articles. So as you can see, in prior years, many people had commented that I'm the harshest critic of many different abstracts. But if you were to note this year, Sruthi actually wins the prize of being the harshest reviewer. On a scale of 1 to 5, note that she was at 2.42. And if you really wanted to ask somebody for money between Sruthi, Matt, myself, or Mary, it looks like Mary is the kindest of all of us. So please consider asking Sruthi not for money. Don't ask me for money. Mary is likely to give you anything that you desire. So please note that that's just a joke, and don't be emailing her at her Harvard Children's address. So the top articles that I'm going to be presenting today are nerve conduction normal values for electrodiagnosis in pediatric patients, and anticholinergic medications for reducing drooling in children with developmental disabilities, and a one-year comparison of a community-based exercise program versus a day hospital-based exercise program on quality of life and mental health in severely burned children. So the first article comes from Muscle & Nerve. This is nerve conduction normal values for electrodiagnosis in pediatric patients. I believe Dr. Conley presented this at last year's AAPMNR session, which I thought was very well received and was one of the articles that I think I will be continually using and referencing, especially as an electrodiagnostician. So note that age has a pretty significant effect on both conduction velocity and onset latencies in EMGs. A lot of that is related both to patient size and the diameter of the nerve itself. Note that larger nerves or nerves that are larger in diameter travel more quickly. Note that newborns have conduction velocities that are approximately half that of adults, which is always a very good question that I have come across on former SAE tests. And they went ahead and identified participants that were of age 18 or younger that were seen at their hospital and electrodiagnostic lab from 1997 to 2017. They evaluated or they looked at all studies that were reported as normal and excluded patients with any kind of neuropathy, obviously any abnormality. Any patient had myasthenia gravis. So that would be somebody that would have some aspect of a neuromuscular junction disorder. Any peroxidine-related disease or autonomic neuropathies. The technical aspects of how they actually performed the nerve conduction studies are included within the paper itself if you want to reference those. But they did have 2,096 initial studies. And of those studies, 1,918 met the inclusion criteria. They ensured validity of the sampling by measuring temperature before the study of each of the extremities that were tested. And other aspects regarding technical functions, regarding the filters and things along those lines are incorporated within the paper. And they reported out both the mean and 2 standard deviations, so essentially what would be the 5th and 95th percentiles of each of the nerves tested and of each of the age groups. So you can see on the table on the far right, they ended up stratifying patients into the following age groups. And they broke them down 0 to 1 month, 1 to 6 months, and farther down as you can see, which obviously they had more patients as you would expect as they entered the pre-teen and teenage years. I don't know how many of you have had the luxury of having to do a study on a 0 to 1 month old, but I'll tell you that is an extremely challenging study to do. So having some reference values, at least in this point, would be helpful. So I'm very happy that they were able to do this. And note that they had, as I said, many patients in that 5 to 18-year-old age range, which is when we may be doing a lot more electrodiagnostic studies in general, compared to some of the younger age ranges when we're doing more genetic studies. I included this, and note this is a normal value in cutoffs for the limbs and the lower extremities, but they also had it for the upper extremities as well as the other nerves that they were checking. I did not intend for this to be an eye exam for anybody who has some difficulty with looking at small numbers. So please note that I included all of the information, or all the information regarding the tests and values are included within the actual paper itself. As you can imagine, when they had this large of a sample size, the data settles over to Gaussian or a normal distribution. The distal latency, as they noted, really decreased from when the patients were born to 1 to 2 years of age, and they thought that was likely due to the level of increased myelination that occurs during this time period. And again, like previous studies have kind of noted, that by about the 2 to 3-year-old age group, values reached adult amplitude both in the CMAPs and conduction velocity values. The strength of this study is obviously the population that was included, the large number of patients, the control of the protocol that's happening within one laboratory, but the limitations is obviously the difficulty in prospectively collecting this information, as all of this was retrospectively collected. The entire population was actually getting an EMG for some reason, so these were not entirely healthy, or patients that had no issues prior to coming to the laboratory, they were obviously coming to the EMG laboratory for some reason. And the stimulations, obviously, in pediatrics is a little challenging, so they occurred from specific landmarks and may not have been set distances. So that was the first article that we were going to cover today. The second we're going to talk about is a one-year comparison of a community-based exercise program versus a day hospital-based exercise program on quality of life and mental health in severely burned children, and I have tried for many years to at least get one article into this top 10 papers that related to pediatric burn, and this year I was able to sneak it past Sruthi, because Mary probably voted it a 5, so we were able to at least get one article related to burns into this presentation this year. So we'll use a couple of different little abbreviations, DAY-X, meaning day exercise, COM-X, meaning community-based exercise programs, both of which have shown some good benefit in positive physical and mental outcomes, but this group really was looking at the hypothesis that they were looking at patients one year post-burn that were able to do community-based exercise compared to if they had to stay in the location where they offered a day exercise program. They really hypothesized that they'd have better cycle social outcomes, and the community-based exercise program closer to where the families lived compared to the day exercise program closer to the hospital itself. This was a prospective study that randomized between the two different groups. It occurred over seven years, and some of the inclusion criteria required a burn over 30% of the total body surface area. These were only for patients age 7 to 18 and had to have an absence of any other acute illness at the hospitalization. They had to have attendance at their follow-up clinic so that they were able to be able to ask these questions about the long-term health and follow-up. They were excluded if they had several other severe health conditions, which were listed there. These were all measured by the Child Health Questionnaire Quality of Life Study, and they used paired t-tests to compare the pre- and post-outcomes, as well as Welch's t-test for the Day-X Convex Comparison. As you can see now, I joked about poor vision, but now I actually need to probably put on some reading glasses, but if you can look at the very bottom on both sides, they actually only had nine patients that they were able to randomize to both the Day-X program and the Convex program. This came out of approximately 1,200 initial patients. Some of their biggest areas of exclusion occurred because the patients did not meet the inclusion criteria of age, and that was one of the biggest challenges that they had, unfortunately, that they were noting that although they were looking for patients that were between 7 and 18, the majority of burns that they saw at their center were under the age of 7. So they did evaluate pre- and post, and they noted that there were both changes in health that occurred for patients that participated in the Day program compared to the community-based exercise program, but those values were not statistically significant as they continued on. One of the challenges with that, or with this study in particular, was that it showed that there was a benefit of both the Day exercise program and a community-based exercise program, but couldn't tell the difference between the two of them. Likely some of this was related to smaller sample size and lower statistical power as a result of that. The family support and cohesion was really equal between the two groups, so that they noted that whether or not the patient was actually discharged and remained near the hospital setting or was discharged and went to the community setting, both of them noted that family support and cohesion was extremely important. They also noted that patients, as they were very close to Mexico, patients that returned home to Mexico did not participate as fully in the community-based exercise programs as those that were still within the United States. Another limitation that was a part of this study was that they noted there was a long time between what was the intervention and the measurement, so they only had the Day program for a short period of time, but then obviously months and months and months later, they actually ended up evaluating the measurement. So they thought that some of the confounding aspects of the psychosocial benefits of being able to go back to a community setting were mitigated by the length of follow-up time between the actual intervention of the Day program versus when they were actually followed up. The last article we'll talk about is from Developmental Medicine and Child Neurology. This talks about anticholinergic medications for reducing drooling in children with developmental disability, and anybody that knows me knows that I'm going to include some pharmacology article if I can sneak it in there. So on this one, Mary probably gave it a 5, and I probably paid through $3.20 to give it at least a 3, so that we'll at least get this article in to talk about this year. So drooling has significant self-care and self-esteem issues, especially in all of our patients that we see with developmental disabilities. Anywhere from a quarter to approximately half have some issues with sciallaria, and obviously many of us use anticholinergic medications to treat this problem, however they have very significant side effects. In this clinic, they recruited 110 patients, respectively, and used a titration schedule over about 2 to 4 weeks of increasing the doses of these three medications. That's benzhexyl hydrochloride, glycopyrrolate, and scalpolamine patches, and then they used several metrics over six different time points to see the outcomes and benefits that were observed during the use of these medications. So those 110 children across the three different treatment groups, 81 received benzhexyl, 62 received glycopyrrolate, 17 received scalpolamine. This was primarily related to provider preference, and if you were to look at the time on medications, it's very fascinating to kind of look at the graph or the pictorial that is A, and those are the patients that are receiving benzhexyl, and you can note that most of them were actually off of that medication by approximately 3 to 4 months, or I should say half of them were approximately off of that medication by 3 or 4 months, compared to glycopyrrolate, where the majority of them remained on that medication at least by that period of time. Very interestingly, the number of patients and the rapidity that people discontinued scalpolamine as a treatment for sialaria was very significant whenever you're looking at the fact that most of them were off of it within six weeks' duration. So what this is kind of showing me is that at least from the perspective of parental perception and caregiver perception, that patients stayed on glycopyrrolate a lot more than they would have stayed on scalpolamine or benzhexyl. In addition, the benefits were also noted from glycopyrrolate a little bit better than they were for benzhexyl or scalpolamine. When you look at the X-axis, B is for benzhexyl, G is glycopyrrolate, S is for scalpolamine, and then on the left are those percents that are still having poor drooling response after initiation of this medication. This was rated by both the caregiver on the left-hand side, so you can see that glycopyrrolate won out whenever the caregiver was rating this. Whenever you're looking at benzhexyl versus scalpolamine, it appeared fairly equal. And then if you were to look at it from the drooling scale that they administered within their clinic, glycopyrrolate was the winner significantly over benzhexyl and scalpolamine. And then if you were to look at some of the adverse events or the reasons why people were actually quitting, on the left-hand side that's what we're looking at as the reason for quitting. For many people, for both benzhexyl and scalpolamine, the side effects were limiting factors. For some of them, there were also poor drooling responses noted primarily in the sialaria group that had scalpolamine treatment. Some of the adverse effects that are listed on the right-hand side, which are kind of related to more systemic-related conditions, you can see whether or not it had a minor impact or a major impact. And the majority of patients wrote that glycopyrrolate did better. Other than some gastrointestinal symptoms, it seemed to be much more well-tolerated. So each medication really can provide at least some meaningful reduction in sialaria. But as we are talking about, some of that improvement is very limited by the adverse effects that occur whenever patients are on these medications. When I will talk to families, one of the big takeaways that I'm going to use is kind of talking about what were the potential response rates from the study, at least related to the drooling scale that was utilized within this clinic. Glycopyrrolate had an approximate 85% benefit, which I think is actually higher than some people would probably recommend or say within their own clinical practice. Glycol and scopolamine were very close seconds, or I should say second and thirds, whenever you're looking at this, because I think most people have adopted glycopyrrolate as really their first-line treatment, and this I think helps support the reasons and rationales behind that. I think scopolamine is very convenient because it comes obviously in a patch form, and you're able to just place it on the skin, and you don't have to worry about an oral administration like you would with glycopyrrolate. So I think that those are the kind of benefits and consequences that you need to talk about with your patients itself. One thing that the authors noted was a limitation within this study is that patients were able to actually discontinue the medications themselves and then report back to the providers when they actually did discontinue this medication, which was really kind of a fascinating turn of events compared to other studies that you would be in if you were in a pharmaceutical drug company study. You may not be able to actually discontinue that treatment, and so really kind of fascinating to see when parents and caregivers actually chose to stop treating these patients based on adverse events themselves or that they were documenting or seeing themselves. So with that, I appreciate any questions that may come up after this. We will have all of these articles posted likely on the Pediatric Rehab Facebook page and potentially even within the AAPMNR Academy site. So please give it up for Dr. Sruthi Thomas, who will be giving our next presentation. Hi, everyone. I'm Sruthi Thomas. I'm a pediatric physiatrist at Baylor College of Medicine in Texas Children's Hospital, and it's my honor to be joining Matt and Mary today on what's now become an annual tradition at AAPMNR to discuss the top pediatric rehabilitation papers. So thank you for inviting me to join you guys. I truly have to say I'm very honored that I now take the rank of being the harshest scorer amongst the group. I didn't see that coming, but I'm really proud of myself because I'm generally the softy. And I will plead the fifth as to whether Matt actually paid me to allow a pharmacology study to be included, but we know he would just be very sad if he didn't get to talk about his drugs. So the first paper that I'm going to be talking about comes to us from a group led by Christy Bjornsson out of Seattle Children's Research Institute that was published in the Archives of Physical Medicine and Rehabilitation that is entitled Low Intensity versus High Intensity Home-Based Treadmill Training and Walking Attainment in Young Children with Spastic Diplegic Cerebral Palsy. So we know, as many of us practitioners in pediatric rehabilitation see on a daily basis, many families of young children with CP often express an explicit goal for walking for their children. And we know that treadmill training is effective at promoting structured walking in young children, especially in this young population where they're highly distractible in an everyday environment. You know, if a child sees a toy or sees something attractive, it's hard to keep them focused and treadmill training allows for a more structured environment. It's also been declared that one of the key priorities in research for CP is figuring out dosing of therapy, how much and how often is actually necessary to get the benefits from therapy. So this group's objective was to compare the effect of low intensity versus high intensity treadmill training on walking attainment and overall walking activity in children with CP. The design was a prospective multi-site randomized controlled trial and it took place in participants' homes. They had children who had spastic diplegic CP enrolled and they had to be GMFCS categories one to two and they needed to be aged 14 to 32 months. So this was an early intervention study. Their hypothesis as predicted was that high intensity treadmill training would lead to earlier walking attainment, increased step count, and overall increased walking activity compared to those in a low intensity treadmill program. So their inclusion criteria, of course, were that the children had to have spastic diplegic CP with bilateral lower extremity upper motor neuron signs. They had to be less than three years of age. They had to have GMFCS one and two and they also needed to show signs of walking readiness and they judged this based off of the child's ability to be able to stay seated for 30 seconds when placed in the seated position and they needed to initiate at least five to seven steps when supported at the trunk and arms. They excluded any children that had uncontrolled seizures, any child that had a genetic syndrome, excluded any child with cardiac or orthopedic contraindications to standing and walking, any child that had had orthopedic surgery in the last six months, and any child that was using a spasticity reducing medication or had had botulinum toxin A injections less than six months prior to the start of study. Based off of their sample size calculations, they expected that they would need about 18 subjects or nine per group, low intensity and high intensity. They had both primary and secondary outcome measures and their primary outcome measure included the gross motor function measurement or GMFM specifically looking at dimensions D and E as well as average strides per day as well as the percent time walking that was measured using an accelerometer. These outcomes were measured at the onset, so pre-intervention, post-intervention, and then one and three months post-intervention. Additionally, they also looked at the Peabody Developmental Motor Scales II or PDMS II, the Pediatric Evaluation of Disability Index Mobility Scale, the Time 10 Minute and One Minute Walk Test, and the Functional Mobility Scale. The children were videotaped while they were doing their assessments, so that allowed for a blinded assessor to actually score the GMFM 66 as well as the PDMS II portions of the outcomes. And they also used a step watch accelerometer to measure the average strides per day and the percent time walking, and to get a nice sample of data, the children had to wear the step watch for a week at a time. So the intervention itself was that children were randomized to either the low, low-intensity or the high-intensity groups. The low-intensity groups received twice-weekly therapy sessions for six, for six weeks, and the high-intensity received 10 sessions per week for six weeks. At the start of every session, each child was encouraged to walk up to 20 minutes per session, but they could stop when they were going to stop. And the treadmill training was carried out by their parents at home, and researchers gave weekly instructions to help the parents. The children would hold on to side rails, and the parents sat directly behind them, giving them as minimal support as possible, but allowing them to stay upright. And they chose the speed on the treadmill by choosing the fastest possible speed where the child could independently move their feet. So for statistics, we've got to go into details here, otherwise I would not be doing math justice, but to look at the categorical variables, they compared each assessment point using analysis of variance for continuous variables and the chi-square test. For longitudinal changes, they looked at linear mixed effects progression models, and to look at, they used both the intervention group as well as the different assessment time points as discrete predictor variables, and they also controlled for GMFCS. So somewhat surprisingly, at least to myself, there was no significant difference between either group, low or high intensity, in any outcome measure at any of the time points. So both groups showed significant improvement in the GMFMD, the PDMS2, the PD, the 10-minute walk test, and the one-minute walk test at each time point after the intervention. And families were able to show a high degree of adherence to the protocols, so that wasn't a variable in this. So the families that were assigned to the high intensity group truly were getting their 10 sessions in per week. And also surprisingly, none of the children showed outward signs of physical strain or excessive fatigue, so they were able to tolerate the home-based treadmill training program very well. So some of the limitations of this study was that when they determined their sample size, their theoretical sample was slightly more homogenous than the population that they were selecting from, so it's possible that it was slightly underpowered. Also, they felt that when they looked at their step watch data that they might have also been slightly underpowered. I think in pediatric rehabilitation research, it's really rare to find a blinded study. They highlight the fact that only part of their study was blinded and that this was a limitation, but I do think that this is a strength of this paper. But one limitation was that there was not a group of children that never received an intervention to really test, you know, how much of a difference the low-intensity versus high-intensity group made compared to having no intervention during that time and just allowing for natural development. So the two-week, two times per week dosage was just as effective in improving walking skills compared to the 10 times per week, and this is great because that's a dosage that can easily be implemented in a clinical setting for therapists as well as in a home exercise program. And I think can also reassure families that even if they can only squeeze in a short amount of home exercise, then it's still likely to be making a difference. So the next paper comes to us from the Pediatric Physical Therapy Journal from a group led by Douglas Barnes, and this is out of the Shriners Hospital for Children and the Texas Women's University, both of which are in Houston, Texas. And this is looking at early mobilization rehabilitation program for children with cerebral palsy undergoing single-event multilevel surgery. So single-event multilevel surgery, also known as SEMLs that many of us have heard before, for the sake of this paper is defined as two or more surgical procedures occurring at two or more anatomical levels in one operating session that requires hospital admission and rehabilitation. So when people have studied SEMLs in the past, we all know that rehabilitation is key to post-op success. However, there's not a lot of guidance in when the therapy should be timed, how intense it should be, and what the setting for that rehabilitation should be, such as inpatient, outpatient, or at the home. So the group at Shriners in Houston, Texas had created an early mobilization program that also included a multimodal pain control plan. And they had found that their patients, you know, anecdotally had been returning to school and daily activities and walking within a month after surgery in most instances. For those of you from centers that perform SEMLs and follow a traditional rehabilitation plan, this is very different because oftentimes children with who undergo SEMLs are kept non-weight bearing for six to eight weeks to allow for bony fusion before they start the rehabilitation plan. So the group here wanted to perform an investigation of functional and technical outcomes to support early mobilization after SEMLs for CP and also disseminate some innovative guidelines emphasizing early walking after surgery. So they performed a retrospective single institution observational study with chart review, and they found 23 patients that met criteria. Their inclusion criteria was that the children had to have spastic diplegic CP, were aged between seven and 17, had a gross motor functional classification scale score of one to three, had undergone SEMLs and specifically included either a femoral derotational osteotomy or a tibial derotational osteotomy, had pre- and post-operative gait analyses. The pre-analyses were often done approximately four months pre-op, and the post-analysis was often around the one year post-op mark. The children in this study also had to participate in the early mobilization program for at least four days to be included in the study. Any children who had selective dorsal rhizotomy, percutaneous soft tissue lengthening, had a back lip in pump, had botulinum toxin injections less than six months before surgery were all excluded from this study since that would add another variable to how well they did with therapy. Their outcome measures included a gait deviation index, so GDI, which was calculated using the quantitative gait analysis, the Pediatric Outcomes Data Collection Instrument, also known as PODC, their walking velocity, reported pain using the FACES pain rating scale as well as observational pain scale, and range of motion specifically focusing on knee extension and the popliteal angle. So their intervention had two arms, so there was pain management as well as early mobilization. Pain management was really controlled with their anesthesia team, which was very aggressive and used both infusions as well as oral medications to get adequate pain control post-op, especially with mobilization. And as far as early mobilization goes, these children were getting twice daily therapy for at least two hours of total therapy in a day. Standing and walking were initiated within two days post-op, and they made sure that they had protected weight bearing so that they would be safe post-op. So, sorry that this is looking very tiny here. Apparently, I, too, believe in having a microscope when studying slides like Matt, but what you can see here is this table actually very nicely outlines their entire protocol. And from the top to the bottom in rows, it goes with pre-op all the way to like post-op follow-ups in the outpatient world, and exactly what assessments and interventions are being done at each phase. So they had a very rigorous and standardized protocol that was being followed for all of these children. They also were very specific in what type of bracing and equipment that they recommended for these children based off of the type of soft tissue procedures as well as lengthenings that they underwent. So the specific equipments that they focused on were the abductor pillow, knee immobilizer, short leg casts, and orthoses. And they again had recommendations for how long in a given day and for how long overall number of days post-op they recommended wearing this. So for the statistics, the pre- and post-data was analyzed using repeated measures t-tests. The post-op pain and length of stay were analyzed using the Welch's test. And overall, the patients were compared as a whole by GMFCS and by type of bony surgery. So the results here, this table here is showing the participant demographics. And the columns, the leftmost column is the whole group. And then they broke it down by those who had ephemeral osteotomy plus or minus a tibial osteotomy. And then the final column is those who just had a tibial osteotomy. And these are all plus minus soft tissue interventions, of course. The key things to take away from this are that it was a predominantly male group. So out of the 23 patients, 16 were male, seven were female. Also, when you look at the demographics, it's actually a very diverse group for being a medical study, but it is skewed towards being a largely Hispanic population. And as you would expect in an ambulatory STEMILs population, the majority of the kids were GMFCS 2 and 3, with only two of them being GMFCS 1. And then you can see here the variety of soft tissue interventions that these children had. Okay. Then this is a table that's looking at pre-op results and one-year post-op results. And again, you have the whole group, and then it's broken down by those who had ephemeral osteotomies and those who had tibial osteotomies. The key takeaway here is no matter how you break down this group, one-year post-op, there's a significant improvement in the GDI, the gait deviation index. So that's your, you know, how pretty do we make them look afterwards as far as how their gait looks, and they all improved. Surprisingly, as far as their walking velocity one year after surgery, the only group that showed significant improvement was those who had femoral osteotomies. But when you look at the group as a whole, they're just those who had tibial osteotomies. They missed the cutoffs for significance. Also, we're looking at the femoral osteotomies. They missed the cutoffs for significance. Also, that's something that's surprising. When you look at the PODC for a global function as their transfers and mobility, and then also pain, you actually see that there wasn't any significant change after semels. So I found that to be a surprising secondary finding. Then when you break it down by GMFCS, I think one of the key takeaways here, you know, pre-operatively, those that are GMFCS1, 100% of them are not using any assistive device versus like a GMFCS3. Every single one of them is using an assistive device. But when you look at kids who are being discharged from rehab, so based off of their numbers, this is anywhere from two to four weeks post-op, depending on how much intervention they had. And, you know, as you would expect, none of them are walking independently. But when you look at one year post-op, you actually see quite a bit of change in the GMFCS2 and 3 population. So the one population, as you would expect, they all go back to not having to use an assistive device. Now in the GMFCS2 population, at the start of the study, only 54% were able to walk independently. But then one year after SEML, 69% were able to walk independently. And when you look at the GMFCS3 category, you have a significant increase where none of the patients previously had been using forearm crutches. They had all been using reverse or forward walkers. But then post-op, we actually have 37% that actually have moved up to only needing bilateral forearm crutches. So that's a pretty significant gain as far as mobility goes. So again, this was a retrospective study, and it was not prospective. And we, of course, didn't have a comparison to traditional rehabilitation after SEMLs. With most traditional rehab programs, having patients be non-weight bearing for anywhere from 16 weeks after SEMLs. So it would be really wonderful to see a study that puts them head to head, but we're definitely seeing some nice gains here. So again, you know, even with the early mobilization protocol, one year out, you're seeing great GDI improvements. But it's unclear whether that's due to early mobilization or not, since we didn't have a comparison arm that didn't have early mobilization. The surgeries were successful at eliminating flexion contractures. But I think a key thing is that when everyone was discharged, whether they were in the hospital for two weeks or four weeks, they were all walking with some type of assistive device, but they were still walking. And walking at four weeks post SEMLs is pretty significant when you consider that most traditional programs are benching you until your six or eight weeks post-op. So overall, there was a significantly lower amount of time before return to school and walking. So the next paper that I'll be talking about is out of the developmental medicine and child neurology. And this is a hot topic from last year's AACPDM, or 2019 AACPDM, where there had been quite a bit of discussion about whether botulinum toxin A injections were actually detrimental. So this study comes to us out of Europe. It's a group of, it's a mixed group from the Netherlands, the UK, as well as Belgium. And it's led by Kat Deslaver, and they produced a study called medial gastroc volume and echo intensity after botulinum neurotoxin A interventions in children with spastic cerebral palsy. So it's been well documented that children with spastic CP seem to have smaller muscle volumes, particularly when we're measuring their medial gastroc compared to those that are typically developed. And there's also some literature showing that their muscles have a higher echo intensity, which is thought to be representative of fat and collagen deposition. So these changes would affect muscular power generation and would in theory be more pronounced as GMFCS function numbers go higher or function, you know, overall function goes lower. And previous literature shows that the effects of botulinum toxin A on CP muscle are mixed, but they also didn't account for natural muscle growth and did not look at muscle structure. So this group's objective was to evaluate whether recurrent botulinum toxin A interventions to the medial gastroc would influence muscle morphology after controlling for GMFCS. So they had three hypotheses, the first being that both spastic cohorts would have significantly smaller medial gastroc volumes and higher echo intensities with respect to the typically developing cohort. They also hypothesized that children who receive botulinum A interventions will have greater differences when compared to the typically developing cohort than those who never received botulinum toxin A. And finally, they theorized that both GMFCS and botulinum toxin A interventions would be significantly associated with a smaller medial gastroc volume and higher echo intensity. So their study was a retrospective cross-sectional cohort study, and they had three cohorts. So the first cohort was children with spastic CP who had received greater than three botulinum toxin A interventions. Second cohort were children with spastic CP who were naive to botulinum toxin A. And finally, they had age-matched typically developing children as the third cohort. Their inclusion criteria included children aged 5 to 16 years of age. They had to be GMFCS 1 to 2. They needed to not have had previous orthopedic or neurologic surgery. And for those who had spastic CP, they either needed to be naive to botulinum toxin A or it needed to be at least greater than six months after their third or more recurrent botulinum toxin intervention. So for their outcomes, they were looking at muscle volume normalized to body mass, so mils per kilogram, as well as echo intensity that was measured using a 3D freehand ultrasound technique. For those with CP, they used the most effective leg to make measurements and those that were typically developing, they used a flip of a coin to decide which leg to use. So they had quite a depth of statistics here, but for the sake of time, I'll let you look at this and dive into deep conversation with Matt the next time you see him if you're interested. And here they show the setup of how they did their ultrasound study. So the child was laying prone and had a wedge pillow under the leg to help relax the muscle. And you can see how the ultrasound image looks and how the measurements were taken of the medial gastroc. So this table summarizes their key findings. So you're looking at the rows, our echo intensity, the volume of the medial gastroc, and the normalized medial gastroc volume, so mils per kg is what you're seeing. The important here is if you look at the right set of columns, you have the comparisons. So you have typically developing versus spastic CP without botulinum toxin, typically developing versus spastic CP with botulinum toxin, and then spastic CP plus minus botulinum toxin. So key takeaways here, the typically developing population was significantly different from all the children with spastic CP, whether or not they had botulinum toxin A injections. So the typically developing children had lower echo intensity and higher muscle volumes overall when normalized for weight. Now, key to this paper, and something that I think we need to take seriously and consider in future, is that the children who received botulinum toxin A interventions did have higher echo intensity and the lower normalized medial gastroc volume compared to those who had spastic CP and never had botulinum toxin A injections. So this slide summarizes the findings from that table. But just to reiterate, the higher echo intensity in the spastic muscle is thought to be due to a higher percentage of intermuscular fat and changes in collagen content. So in this case, it's possible that botulinum toxin is leading to this difference. Now, quantifying the ankle joint resistance and muscle activation, and then evaluating the impact of botulinum toxin A interventions in serial castings would probably provide more insight. And then of course, both a botulinum toxin A history and GMFCS level are significantly associated with the echo intensity and muscle volume as had been theorized. So one of the limitations is that this was retrospective and not longitudinal. And then of course, those children who had undergone botulinum toxin A interventions might have also had serial casting or physical therapy after being injected. And there's no way to know how much of a role those interventions played in the changes that they saw. So in conclusion, recurrent botulinum A injections may cause alterations to the medial gastroc volume and echo intensity, indicating that there might actually be a long-term impact of getting recurrent botulinum toxin injections, which would lead us to say that this needs to be investigated further, given how often we use it in our practice. So I'm going to turn it over now to my partner, Mary Dubon. Hi, everyone. And so I'm Mary Dubon. I'm a pediatric rehab physician through Boston Children's Hospital and Spalding Rehabilitation Hospital. I didn't realize I was the biggest softie, but I should have realized that when Matt decided to give me four of the articles to present rather than three. So now I know for next time, for sure. So I have a few disclosures there, though none are related to the articles that I'll be presenting today. So the first one that I'm presenting today is on anti-NMDA receptor encephalitis within the inpatient rehabilitation unit. And so this is a great study that I feel like is super relevant to all of our practices. You know, as we know, anti-NMDA receptor encephalitis really is a relatively newly described diagnosis, but is likely the second most common autoimmune cause of encephalitis. And so this study was looking specifically at the pediatric population. There's been some studies of adults and specifically looking at functional outcomes and predictors of early recovery in pediatric patients with anti-NMDA receptor encephalitis, specifically within the rehab setting. So it was a retrospective chart review over a number of years between 2010 and 2017, and they included patients who had the diagnosis and who were admitted to inpatient rehabilitation. And they looked at the demographics and the clinical variables, and they did have WEFIM scores to look at as well. So they looked at certain treatment variables and tried to look to see if there was any correlation with these variables and with functional outcomes. And so one was time to treatment. So that was days from symptom onset to the start of their treatment within acute care. The other one is number of treatments. So we'll go through, there's a number of different treatments that patients do get. And so if they got one versus getting five, does that make a difference? And then they also looked at length of stay on the rehabilitation unit within number of days. So they looked at descriptive statistics as well as correlation testing to go ahead and analyze this. And so when we look at their study, it was obviously a relatively small sample, but considering that the diagnosis is not a super common one, they had a pretty good number of patients. Average length of stay within the rehab hospital was 39 days, and it was truly a pediatric study age range between 2 and 18, average age of 10. So I thought this was a little interesting too. So just giving some background of their diagnostic test results in terms of many patients actually did have some findings that were normal, like initial MRI, but oftentimes patients had positive testing with their LP, CSF, and some patients with serotoma. These are the list of the different treatments in terms of first-line treatments, steroids, IVIG, PLEX, and second-line treatments, things like rituximab. And so they looked at number of treatments received with some patients receiving one or two, a decent portion of patients receiving three and receiving four or five. And so then this table here, this graph looks over the pre- and post-scores essentially. So looking at the LIFM different modalities there. So looking at self-care, comparing from admission to discharge, mobility, cognition, and total. And there was obviously quite a range per patient, but there was an increase that was shown in terms of admission to discharge for all of these areas. And then this bar graph here shows level of dependence or independence. And certainly, it's simplified in terms of three categories of total assistance, partial assistance, and then independence. But the real good takeaway from this is that by and large, the large majority of patients did require assistance at some level, although a lot of impartial assistance at the time of discharge from acute inpatient rehabilitation. So overall, they did actually see significant functional gains during their inpatient rehabilitation stay. Some things that were actually correlates with worst functional outcomes were younger age at onset, seizures, higher number of treatments that were received. And there was actually no correlation, which I thought was interesting as well with functional outcomes in terms of time it took to get their initial treatment. So in terms of takeaways and how we apply this to practice, I think it's great for us to see that patients by and large did show improvements within patient rehabilitation, which obviously justifies the work that is done with these patients on the rehab unit. Most patients still did have some functional impairments at discharge, which helps to prepare and also to prepare in terms of resources and follow up for patients after discharge. And then knowing a little bit more about those factors associated with worse outcomes can help you anticipate the patient's needs, anticipate length of stay, and then some prognostic counseling with patients and families as well. Clearly, further research has indicated that this was a great start for this population. So moving on to the next study, now we're looking at prenatal repair of myelomeningocele and comparing that to the school age functional outcomes. And this was a big and great study that was really a follow-up to the initial mom study that many people know about. So the initial study, the management of myelomeningocele study was randomized in terms of prenatal versus postnatal myelomeningocele repair. And so this is the moms to study. It's a component of it. And now the children fast forward, it's those same patients, but fast forward in those kids are now school age. And so there were a number of different tests that were done for these kids. Obviously, families that wanted to participate in the second wing were included. And there were adaptive behavior skills, motor function skills that were used, actually did some brain imaging on patients, neurocognitive measures, behavioral measures, and then also quality of life and impact on family measures as well. There were three sites that were part of the mom's trial initially. So that's where the patient population came from. And then the data coordination happened through George Washington. So again, it was voluntary enrollment for patients who were previously in that study. And then they basically did one comprehensive study visit when the patient was between ages five to 10. They did comment that they were hoping for patients to be at least six at the time of their evaluations. And they did, again, pretty comprehensive testing from a functional perspective as well as brain and spine MRI and urologic testing, although the urologic testing is presented in other papers and not as part of this particular paper. So data analysis was complex. Given the complexity of the data, they did use an intention to treat model. And there was testing for the continuous variables, the categorical variables. And then they also did some correlation and testing as well as looking at a sensitivity analysis to make sure those who were in the first group who did not participate in the second group, making sure there weren't any major things that stood out there too. So again, a lot of the stuff is small as everyone else has been commenting on. But for sure, if any of these studies have piqued your guys' interest, the best way to learn more about it is to read the paper directly yourselves, which again, all of us, I think found these papers to be particularly interesting. So we definitely recommend it. So what I found interesting about this is there actually was a pretty high percentage of patients who were in the initial study who wanted to participate in this study. And it was pretty even in terms of dropout with seven individuals lost to follow up on each side. And demographically, the big thing to point out here is that from the initial study, there was a difference in terms of gender and sex. And so female sex being a bit more prominent with the individuals in postnatal surgery versus prenatal surgery. So there was some correlations and some adjustments made because of that. So one of the big things they wanted to look at is adaptive behaviors. And was there a difference between the prenatal surgery and postnatal surgery group? And they actually did not find that even though the hypothesis was that they thought adaptive behaviors would be different. They did find some other things that were different in terms of function, particularly walking status. And they also found that shunt placement and shunt revisions were more frequent among the postnatal surgery group compared to the prenatal surgery group. They also found that with MRI findings, there were some more significant or concerning findings on the postnatal surgery group compared to the prenatal surgery group on those repeat MRIs that were done. And then looking at quality of life and impact on family, there was a statistically difference between the groups as well there with the prenatal surgery groups indicating a bit higher on that aspect in terms of quality of life. And then the total impact on family was considered to be higher for the postnatal surgery group compared to the prenatal surgery group. So really, again, the big takeaway, I think from this paper, no difference in adaptive behavior, but the prenatal surgery group did show increased mobility, increased independence, less shunt surgeries and shunt revisions. And certainly we did see a difference in terms of impact on families and quality of life as well. All right. So the next study is subtle motor signs in children with chronic traumatic brain injury. And so when we're talking about subtle motor signs, what we're referring to is motor or sensory abnormalities that are not easily localizable to specific regions of the brain. And so they had some specific questions about this. And it's an interesting area. That's something that's pretty new to be looking at. So it was a small study, and I think that's definitely one of the limitations of it, but definitely some pilot work that I think can be expanded upon. So they took 14 patients with traumatic brain injury who fit these criteria, and then they compared it to 14 age match controls. And so they did a specific test of the physical and neurologic examination of subtle signs to look for some of those subtle motor signs. And they also had MRI imaging and did some calculations in terms of the total cerebral volume and then the ratio of motor to premotor cortex volume as well. So statistical analysis were pretty straightforward, kind of looking for comparisons, but then also looking for correlations as well. And so there was some difference that they noticed in general between controls and between those with traumatic brain injury in terms of subtle motor signs. But they did notice also that there was some difference in terms of total cerebral volume. And then we'll see the next diagram here, which is kind of interesting. They looked at that ratio of motor to premotor cortex volume to that subtle motor score test score. And they showed that there was actually a correlation between the two for patients with traumatic brain injury, while there wasn't really a correlation between the two for patients without traumatic brain injury. So not to go into these in great detail, but I do kind of show you a little bit more specifically about what they look at with those subtle motor sign tests. And they have pretty good details on the 14 patients and what types of brain injury they have. Because I think something that's very interesting with brain injury research is there's such a variety of types of brain injuries that folks can have. And it does make it a little bit hard to compare groups and to have a very similar group amongst a group of patients with traumatic brain injury. So really, I mean, again, pretty early research. But it did characterize some subtle motor signs do happen in pediatric patients with traumatic brain injury. And then it established this as a tool that can be used for this purpose. So last but not least, so the last study that we're going to be going through is looking at difference in continent rates in individuals with spina bifida based on their ethnicity. So there actually have been some prior studies that showed ethnic disparities in continents among patients with spina bifida, but those studies were regional. And so this study actually is a national study using the national database to investigate differences in bowel and bladder continents and interventions for bowel and bladder between individuals of different ethnicities. And so it did use the National Spina Bifida Patient Registry. And it was using data from 2009 to 2015, patients age 5 through 21, and looking at various variables, including the specific spina bifida diagnosis, ethnicity, basic demographics, functional level lesion, and mobility status. And so they looked at some basic statistics. And really, their focus here was really to kind of compare groups and see if those things that they saw on the regional studies were similar to what they saw in the national study. And so again, I don't expect you guys to be able to see the whole diagram here and would definitely refer you to the paper. But some things that really come across with the demographic table is that most of the patients have myelomeningocele in terms of their spina bifida diagnosis. 25% of the population was Hispanic or Latino, which also was helpful in terms of representation to make sure that we're appropriately looking at that comparison. And then the next two tables kind of go through their regression analysis. And I have kind of here their conclusions in terms of what they saw from all that. So they did actually see that there were lower rates of urinary continence, and that all of these findings that I have listed here were statistically significant findings. Lower rates of bowel continence, lower rates of private insurance, lower rates of bowel surgeries, lower rates of bladder surgeries, and more vesicostomies. And so they did find fairly significant differences based on patient's ethnicity. And so health disparities certainly do exist, particularly as this study showed for Hispanic or Latino patients with spina bifida. And clinicians really should kind of take things to the next level and say, okay, let's show you why are these disparities existing and how can we use this information to try to narrow that gap and improve health equity in this population? And I thought the researchers did a really great job of saying, okay, great, now we've kind of shown this on a regional and a national level. Let's kind of focus our efforts for future studies to try to figure out how to narrow that gap now that we know that there's an issue so that we can improve health equity in this population. And so with that, that's all that we have here today for our top papers. So thank you guys so much for tuning in. Please go ahead and fill out the evaluation form and give us any kind of feedback you have, because we're always looking to improve these lectures and hope everyone has a great day.

pediatric rehabilitation

nerve conduction

EMGs

exercise program

quality of life

mental health

anticholinergic medications

functional outcomes

traumatic brain injury