All right. I see everyone logging in. We're gonna get started here pretty soon. I'm pro speakers, I'll let you know when there's about two minute warning when we're getting close to that 15 minute mark just so we can stay on time make sure all each of the presenters have their fair share of time and whatnot and definitely make sure we got time to hear what Dr. Bulger can give us in terms of clinical insights and whatnot as well. So try and keep that 15 mark as best you can. Okay. Okay, we're at that 802 mark so let's go ahead and get rocking. So welcome everyone to the AAP Medical Student Council's Journal Club. This month we got a really awesome topic of pediatric rehabilitation, a lot of great presenters. First off, we have our great clinician expert who's, we're very excited to join us. We have Dr. Ashley Bolger, Assistant Professor of Clinical Pediatrics, Division of Rehabilitation Medicine at the Cincinnati Children's Hospital out of the University of Cincinnati College of Medicine. And then we got a lot of great presenters. First one tonight, we have Hamza Sulpan, a second year med student at California North State University College of Medicine. He'll be talking about the effect of psychologically informed intervention to treat adolescents with telephemeral pain, a randomized controlled child. So go ahead and take it away, Hamza. Sure. Sulpan. Sulpan. I think I told you. Yeah, my bad. My bad. But that's okay. Okay. So. Okay. Can everyone see that okay? Yep, yep. Yep. Perfect. So hi everyone. As Nathan introduced me, my name is Hamza Sulpan, I'm an M2 at California North State University. This is my first time in one of these Journal Club live sessions as well, so it's a great time to present, a first time for everything. lots of new faces, but I do see that Eric Jones is on the call and he's been a great mentor, a fellow classmate at CNU, so that's great to see. And so today, the article I'm talking about covers patellofemoral pain from both a physiological and a psychological perspective. So our article is Effect of Physiologically Informed Intervention to Treat Adolescents with Patellofemoral Pain. And so, you know, we're going to go over the introduction for this study, the study design, the methods that they use in the study as well, results and the discussion, and then sort of just a recap of the salient points. So to define patellofemoral pain according to this article, it is any injury to the cartilage underlying the knee that leads to pain with bending activities. And it's important right off the bat to note that, of course, patellofemoral pain is a spectrum. There's patellofemoral pain, which is mild and chronic, and there's acute pain, which may lead to debilitating features. However, when we look within patellofemoral pain in the adolescent group, it does give key prognostic clues to what's going to happen down the line, down the pipeline. And what we see is that those adolescents with continuous patellofemoral pain are highly likely to report pain and dysfunction years post-initial diagnosis. And so the question remains, what are ways to prevent the development of these debilitating features of patellofemoral pain? And so when the study designers were looking at past studies, they discovered that perhaps combining a physical therapy approach, the traditional approach to patellofemoral pain with a psychological component could help. And the study that they cited and what they heavily based the methodology of the study is based off was the SCOPA study, which stands for the Sequential Cognitive and Psychological Approach. And I'll talk about the methodical similarities in the study design section, but essentially what they did in this study was it was single blind. So the researchers and the proctors knew that they were giving a psychological video to one group, combining it with the physical therapy approach in the control group. And so they were able to see certain benefits, but because of the limited sample size, they couldn't extrapolate significant conclusions from it. And so the goal of this study was to combine the same psychologically informed video education with a physical therapy modality and see if it can improve function among adolescents with patellofemoral pain, as well as the psychological components of fear, pain-related fear and pain catastrophizing, both of which I will cover in a moment. And so some important differences from the aforementioned study are that this was double blind. This meant that the proctors of the study also were privy to whether they were training people who have been informed with the psychological video or just the control group who is just receiving the physical therapy that they proctored. And it's important to note that the proctors did not receive the video training. It was only given to the outpatient physical therapy patients. And so there were 66 total participants within the 12 to 17-year-old age range, and they were all presenting in a certain pediatric hospital. And between the experimental and control, you had 34 and 32 respectively. And as for the video itself, it was a 10-minute video. It was a collaboration between a clinical psychologist who takes a non-pharmaceutical approach to treating chronic pain and a physical therapist who was trained for 10 years to deal with patellofemoral pain. The three components of the video were, first of all, giving an overview, defining patellofemoral pain, what it is, de-stigmatizing the fear and defining it in layman terms. The second was talking about the causes of any combination of joint trauma and psychological stressors. And then third was giving a realistic timeline for the patients to follow. So this was the same video that they followed. And within this study, those in the experimental group watched this right before completing the beginning of their traditional physical therapy program, which was two one-hour long sessions per week. There were several self-report measures that were used within the study. These include measuring function and pain, as well as the psychological measures. And the intervals for the self-report measures are put below. And it's important to note that these followed the prior study that it was based on as well. As for the tools of measurement, so I'll just kind of go into these. So the anterior knee pain scale, you can see that it has a quite a wide range. It's a score of zero to 100, with 100 being no disability. And it is based on self-report questionnaire asking patients about their certain abilities and their quality of life related to patellofemoral pain. And it's considered to have excellent validity and reliability. And so we're looking at quantifying changes in function for the patients. The second is the numeric pain rating scale. And this has a much more narrow range. And its range of time is within the last 24 hours. So it can give more qualitative info, but it's not as wide of a range of values. So there could be some overlap. And of course, pain being subjective has to be taken into account. And this is why it's considered acceptable for use in adolescents, but not necessarily in older age groups. And then finally, the psychological beliefs were assessed with the following studies. And I just want to take a moment to define pain-related fear and pain catastrophizing. So pain-related fear would be just, you know, fear related to the certain pain associated with an activity given a certain disease. But pain catastrophizing is taking that experience of pain and imagining the worst outcome possible. And so we're going to see important differences between what a patient's or apparent association between what a patient's baseline level of pain catastrophizing was and whether or not this psychologically informed video was able to make a difference within the treatment program. And so below are the results. And I'm just going to take a moment to touch on the three components that we can see below. For function, which is the graph to the far left, you can see that the anterior knee pain scale, again, being a scale of zero to 100, can give a wide range. Even with this being the case, in between group differences between the control group and the experimental group, there were not significant between group differences at any individual assessment point. And there was a greater change observed in the experimental group over the period of three months total. So 8.9 points on the anterior knee pain scale. But it's important to note that this was not determined clinically significant given the span of the treatment program, three months. As for the results for pain, we can see no significant between group differences in the reported pain with both having clinically significant improvements. And again, this is based on a combination of the anterior knee pain scale and the numeric pain rating scale. And we'll get a little more into depth as to the, as you can see, there is a baseline difference between the psychologically informed group and the control group. And this is touched upon in the study as well. And then finally, as for psychological beliefs, there was a statistically significant reduction in the measurements and quantifying pain-related fear and pain catastrophizing with the psychologically informed group, as opposed to the control group, significantly noted from baseline to two weeks, but not afterwards. So not for the total three month period of the study. And so now to sort of discuss the points a little further, first, we have to ask why was there no clinically significant difference in function? We, earlier, we mentioned that patellofemoral pain has been determined to be at, you know, at an interface, especially long-term prognosis between psychological structures and of course the physical aspects of the condition. Why wouldn't we see a difference in function then? Well, as I noted earlier, there is a marginally lower function within the baseline of the experimental group. Although the sample sizes were overall the same, we used an age-related or an age group from the same hospital, there was a different level of function and therefore perhaps this influenced the ability to compare them evenly, especially over a period of three months. As for, again, tying it back to pain-related fear and pain catastrophizing, it appears that pain catastrophizing was not as alterable as pain-related fear, at least with regards to the video that was administered. Perhaps it didn't do as well of a job of addressing pain catastrophizing. And this is clinically important because prior studies that look at patellofemoral pain, especially long-term prognosis, note that high pain levels are associated with pain catastrophizing. So perhaps a video which could better address these unrealistic beliefs about pain in the long-term could do a better job addressing pain and reducing the experience of pain as well. And again, even within that note of psychological changes and the effect on pain-related fear, that the difference was only significant from baseline to two weeks. So while it can describe a beneficial effect within that two-week period, beyond two weeks, six weeks to three months, it is not clinically significant. And as for looking at the factors, again, patellofemoral pain, using a broad definition to encompass a condition with wide presentations, this makes it difficult to certainly determine whether or not the psychologically informed intervention has equal benefits. And again, I just want to highlight the benefit that was observed with regards to those already having elevated pain-related fear. Perhaps screening tests or surveys that are able to assess pain-related fear prior to the administration of a physical therapy program would do a better job at determining who would benefit from these programs. That leads to the final point that I think is important, that the fact that this study design was in itself a replica and an alteration of a former study design proves that there's many opportunities to make slight adjustments. Perhaps future studies want to find, you know, maybe as limited of a sample size, but a group with very comparable function at baseline in order to limit the effect that this has had on the study. Perhaps screening before in a large population can help you determine who's already at a high risk of pain-related fear and poor outcomes from that and would be a good study subject for this as well compared to a control group. And then I want to touch on the limitations as my last point. The significant psychological differences in the experience of pain and the experience of life as well make it unfair to generalize the findings of this study to the findings that we would expect in adults. And again, it was suspected that the psychologically informed content by therapists was a potential confounding factor, perhaps that the therapists that were in this group were not necessarily trained for their prior experience dealing with the psychological aspects of pain. However, if this was the case, perhaps we would have observed a greater difference in psychological beliefs in both the pain-related fear and pain catastrophizing. This is a point noted out by the authors of the study just to be transparent and fair with their study design. And as for the initial between-group difference, there are several factors that may point to the fact that this was not a limiting factor on the study. For example, for the patients who were included for patellofemoral pain, they had an equal and chronic duration of the diagnosis, so they were diagnosed at a similar time within a very narrow period of a few months. And again, they observed a similar rate of improvement post-two-week follow-up. And these are my references, and thank you. Perfect. Sorry about that. And sorry, sorry for all the technical difficulties tonight for y'all y'all, um, entering everything. We're trying to get all that stuff removed from the chat, unfortunately. So we're gonna get that all sorted out before our next presenter here. So my deepest apologies for our audience here, our presenters. Fantastic job, Hamza. Sorry for all that going on in the background, unfortunately, but we're getting everything sorted out for you. So thanks for all of the punches. Um, really great presentation. Um, let's kick on over to Dr. Bolger to weigh in and kind of give us some extra clinical component to this really common pain syndrome. Yeah, great job. Um, you know, I will say the caveat to this article, um, is that is most of us who are peds physiatrist, we actually don't do a lot of sports medicine by the time we get done with fellowship. Um, so I don't know the last time I saw a kid with knee pain in my practice, but, um, but I think takeaways for me would probably focus more on the pain things. So I think just driving home the point, and I would assume that most of you on this call, or if not committed to physiatry, highly considering it, if you're here, um, you know, how important just the, the mental aspect of recovery and going through this process is. Cause I think that's what kind of stood out to me. Um, you know, both of the groups improved. I mean, you can see that on that nice figure. I don't remember which number it was, but you're too, you know, they both got better and that's what we expect for, for patellofemoral pain based on the, uh, the stuff that they told us. But, um, but the people that, you know, had a lot more pain to start with, not only were they worse, but they also got a little bit better once you dealt with and gave them the tools to deal with that. So I kind of thought of it more as like, you know, the athletes that might have great recovery versus the athletes that might not have as, as good of recovery and what bucket do they fall into? So kind of like you had said, like, you know, is there a way we can screen for them and kind of identify those people up front? So that was kind of my biggest take home point from all of this, not, you know, doing a lot with patellofemoral pain anymore in my life. So I cannot comment a lot clinically on knee pain whatsoever, but we'll go with anything. Great job. Thank you for that, Dr. Bolger. And then, you know, we have a large audience here. Um, if anyone's got any questions, it's time to ask them for Dr. Bolger Hamza. I just know you have any questions. Yep. Hi guys. This is kind of funny. This is the first time I've ever been to one of these and this research project or this paper was super cool because it was similar to a research project I did this summer on femoroacetabular impingement. So another super common thing with no straightforward way to treat it. And one of the things that we found in it was that some of the differences in treatment and outcomes could be because of the morphology of the hip. So like overgrowth of the femur versus overgrowth of the hip and the acetabulum itself. So I'm curious with this one, are there like different morphologies of patellar femoral conditions or did they account for that in this study or was it all just people who had the diagnosis but didn't really account for the differences in morphologies or what actually was causing their pain? That's a really good question and a really good point. I think the topic, I'm going to say this with a caveat again, because I don't know that I am like the 100% best person to talk about this anymore, but in general, from what I can remember for this kind of, I'm going to say general term, so patellar femoral pain, is there's lots of potential different etiologies for it. So I think of it for a lot of different reasons. Like, you know, in the older individual, could you have some anatomic abnormality of your patella, so it's causing some rubbing and that sort of stuff. That doesn't typically happen in kids because you don't have some of those like OA type, you know, etiologies. But in kids, there's lots of different reasons. I think, you know, tons of them are like muscle and tendon and ligament imbalances and they're moving in a way that they shouldn't be in kids or doing something inappropriately when they're doing various training mechanisms. But they kind of lump it, a lot of it just gets lumped into patella femoral pain and kids like they don't go, my recollection is don't usually go down the, you know, pathway of what exactly causes it because we know if we do certain, you know, certain strengthening to get, you know, like quads and, you know, different things, they get better. And so there's not necessarily a reason to go down the like, let's image, let's do all this stuff. So most of these kids get clinically diagnosed and never get imaging like that, from my recollection. Thank you. Did they mention anything in the article to Hamza, if you want to comment to that, that was super helpful. I'm just curious to know if maybe they accounted for the morphologies or anything. You know, from what I read, there wasn't too much in depth of how they recruited participants. It seemed more so out of convenience, you know, from certain pediatric hospitals with this diagnosis within the month range of April to October 2019. But that would be super insightful if they did. And actually, Dr. Boulder, I have a question. So again, maybe you can use some other condition that's similar to patella femoral pain, even if you don't deal with it too much yourself. But could you talk about the interface between the psychological aspects of pain and the physical objective aspects, you know, morphology, imaging studies, and how that relates to an approach to long pain? Oh, for sure. That could be a whole like, two day course or more to talk about just that topic. I think, you know, there is so much to unpack there. But I think, you know, in simple terms there, we know there's a huge interface between psychological aspects and pain, both acute and chronic pain. You know, I do a lot more in the chronic pain world in terms of like inpatient rehab programs for that. So this is kind of where my knowledge lies and my clinical experience, but gosh, is there an overlap? And honestly, you know, that's a big focus for most people, you know, especially in kids that deal with chronic pain is, you know, you got to treat the psychological parts of it first. And so, you know, things like our inpatient rehab, pain rehab program, you know, a good chunk of it is cognitive behavioral therapy, working with our pain psychologists on, you know, reframing things. And I think for a very, very, very long time, people underestimate that. And I don't think it matters what diagnosis it is. I think it doesn't really matter at all what diagnosis it is. I think if you're not in the right mindset and you've got some of these other things going on, it's going to be a much more challenging recovery overall. And maybe that's a lot of the reason why some people have great recovery from various things and others, you know, don't have as great of recovery for, you know, no anatomic or injury based reason. I don't know. But gosh, there's a lot of overlap and y'all will be dealing with it the rest of your lives. Welcome. Cool. Thank you both. Awesome. So great discussion on our first one. Again, sorry for things kind of going array in the chat here. We're trying to get it cleared up still, but keep rolling with us. Thanks everyone for their patience and flexibility. Obviously, nothing on purpose there. We'd probably just gotten baited by a bot unfortunately. So let's keep rolling with the punches. We've got great presenters coming up here too. So we got Shandan Saini, a third year med student at the Midwestern University Chicago College of Osteopathic Medicine here to talk to us about functional outcomes of pediatric patients in short-term pediatric rehabilitation intensive therapy or the sprint while receiving acute oncologic and hematologic care. So go ahead and take it away when you're ready. Definitely. Hello, everybody. Okay, there we go. So my name is Jonathan Sanney, third year medical student at Midwestern University Chicago College of Osteopathic Medicine. And presentations, as Nathan said, functional outcomes of pediatric patients and short-term pediatric rehabilitation, intensive therapy, aka SPRINT, while receiving acute oncologic and hematologic care. Before I wanted to continue this presentation, I wanted to start with a quote from Martin Luther King, just because it was Martin Luther King Day yesterday. And I thought it would fit very well with this month's focus on pediatric rehabilitation. And it's, if you can't fly, then run, if you can't run, then walk, and if you can't walk, then crawl. But whatever you do, you have to keep moving forward. And just like as a job as a physiatrist, just to give not even just patients, but children the hope and inspiration to get back into a strong functional state, and just have them just be a kid. So some background information. With modern medicine, there has been an increase in survival rates with children going through, hold on one moment, trying to move this toolbar. Okay, there we go. So with modern medicine, there's been an increase in survival rates because, yeah, modern medicine, but that has resulted also a decrease in daily function, specifically reduced strength, balance, and functional mobility as people live longer, or even just having gone through treatment, there are often those complications as a result. And there's a study that showed that physical activity were significantly lower in inpatient stays compared to stays in outpatient. And in fact, that half of children who were receiving cancer-related care, they had received physical activity for three to five days a week, and 18% of them received physical activity less than three days of the week. And their activity ranged from sitting at the edge of the bed or in a chair, standing, or simply ambulating in a room. And then another meta-analysis study has shown that incorporating exercise during an inpatient stay has improved children's functional mobility and their ability to participate in activities of daily living without affecting their mortality or relapse. So the problem that this study was trying to address was that even though these children are being admitted to these inpatient hospitals and could have some PT and OT, often the times the medical care that they were receiving would impact the rehabilitation. And so they created this program called The Sprint, which was tried to alleviate that problem. And yeah. And so the program itself was developed at Seattle Children's Hospital. And the patients were on the hemog and bone marrow transplant unit. And then the therapy goals, they were to address the functional mobility, the gross and fine motor skills, strength, range of motion, activity of daily living, cognitive linguistic skills, swallow, and then and or feeding function. In terms of the structure itself, it consisted of two to three hours of daily PT, OT, and or speech therapy on weekdays for two weeks. And the goal of each therapy was to be 60 minutes. But for patients who are younger or just weren't as conditioned, their therapy sessions were to 45 minutes. And then on the first day of the program itself, it consisted of a meeting with the patient, the patient's parent or guardian, and the health care providers, which included hemog physicians, PM&R, and the patient's nurse. And they were, one, going to review the program expectations, establish functional goals, and exercises the patient can do outside the therapy sessions, but also just to promote uninterrupted therapy sessions. And they did this by displaying the schedule outside the room on top of a sign saying that a session was being placed, just because in hospital stays, medications have to be administered. Sometimes procedures have to be done, and so that can impact timing and scheduling of when these patients can experience their therapies. And then on the last day of the program, it was to then review all the progress that was made, as well as any additional short-term or long-term goals that still need to be addressed and any other rehabilitation plans. And so some measures that they were trying to focus on, one, they used a questionnaire, which comprised of four questions, and they gave it to the parent, as well as each participant who was seven years of age or older, the start and end of the program, as well as another evaluative measure called the Pediatric Evaluation of Disability Inventory, aka PD. And this was to measure the functional status of children in between, and it's used for children between the ages of six months to seven and a half years of age, but it could also be used for patients who were older than seven and a half years of age if their conditioning was less than the normal peer at their respective age. And with the PD, there's three domains within it. There's the functional skills of children, there's a caregiver assistance, and then a complex functional activities portion. They only use the caregiver assistance portion just because if they were to do the whole PD, it would take the whole therapy session to complete, because it's over 250 questions. So they focus on primarily the caregiver assistance as a great way to track the patient's progress. And so the inclusion criteria for this program was for patients that were experiencing significant functional decline during the hospitalization, they require two more therapies of either PT, OT, and or ST, and they had to be able to participate in sessions that were 30 minutes or longer. And they had to be also be patients that would have been considered for an inpatient rehabilitation service, but they were unable just due to the amount of medical treatment required for the hematologic and oncological diseases that they were going through. And then lastly, the parent or guardian had to obviously agree to the child's participation in the program because they are minors. And so the demographics. So there was 18 patients in total, they all had generalized weakness and deconditioning as a rehabilitation diagnosis. The most common neurological disease that they were going through were leukemia, lymphoma and CNS tumor. And 10 of these patients were receiving chemotherapy. The most common complications for nine of these patients was a systemic infection, whether it was bacteremia, or fungemia, due to being immunocompromised from the chemotherapy. And then prior to starting actually 16 of the patients, 16 of the 18 were in the ICU for an average of 10.6 days. And the average length of stay for the sprint participants, including the sprint two week training time was 68 days. But what I really wanted to get at was that these kids were really sick and very deconditioned, and they were going through a lot of complications. And in fact, actually one patient had unfortunately passed away during this program, just due to a very prolonged hospitalization, and the bacterial progression, neurologic deterioration with eventual withdrawal, of course. And that person's hospitalization stay was 344 days, almost a year. Mentions of the results of this study was that one, there was a significant change that was discovered in all of the PD caregiver assistance levels. And then you can see that here in self-care and mobility. And I just wanted to say that this program did demonstrate an overall reduction in the assistance needs of these participants. Some other facts that aren't listed in this table specifically, but they incorporated in the results sections was that the average number of PT days was 8.39, and 84% of it was completed. Average number of OT sessions was 8.83, and 88% of it was completed. And out of those missed sessions, 71% just due to the patients being very tired and fatigued of note. There was no adverse events at all during this rehabilitation program. And at the very end, out of the 18 patients, nine were discharged, six transitioned to additional intensive therapies, and then two were transferred to a care facility closer to home, and then that one patient had unfortunately passed away. And then towards the bottom, you see the social function category right here. And there's only seven participants in this, just because this category only had been analyzed by speech therapists, and only seven of the patients needed speech therapy. Within this, just functional expression was statistically significant. Moving on in terms of conclusion. So the SPRINT program, it is a pilot rehabilitation program that provides inpatient rehabilitation therapies for pediatric patients who are going through these hematologic-oncologic diseases. But it's specifically meant for these patients who are not able to transition to inpatient rehabilitation due to the fact that they just require extensive medical care. And this program has resulted in significant functional gains for the children, and just help them get back to a state where they can just be a kid again. And another thing was that, again, it's a safe program with no adverse events. Of note, there was no difference in terms of the patient's levels of tiredness, sadness, nervousness, or pain between the start and end of the program. Some limitations of the program itself, one, it is a two-week program. Some of these patients could have benefited from a longer duration of an intensive therapy. So six of the patients did require more rehabilitation services. And then two, in terms of the PD functional measurements, again, they had only used that caregiver assistance domain, not the other two domains. And so there is some, I guess, lacking information in there. And then another limitation was that the use of PD for older children, an alternative functional measurement tool may be appropriate for patients who are seven and a half years or older, rather than using a evaluative measure that was specifically meant for six months, and then two, seven and a half years of age. And then in terms of the questionnaires, I didn't include the questionnaire data just because there was no statistical difference that was found with that. And it was a pretty small sample size, only 11 questionnaires were completed by the parents and four by the patients. And then in addition with the questionnaires themselves, there are a couple of other questionnaires themselves. There could have been just a high amount of bias because as parents, they want their children to typically do well, and that could influence how they answer the questions. And then in terms of future directions for the study, just as this increased data collection, as additional programs like this incorporated in different hospitals, and then two, just another evaluative measure for PD that could better, I guess, measure the functional gains of participants in these studies. And those are my references, and that's the end of the presentation. Awesome. Great work. Go ahead and stop sharing, and then we'll kick it over to Dr. Bolger for her thoughts. Cool. I was going to say, I can start talking. So this is a great article. So I don't know if you guys choose the articles or how you guys determine it, but I was really excited. I had read this article before. We had actually done it in our PEDS Rehab Journal Club with our fellows and residents, mostly because, so here in Cincinnati, we have a very similar program to this. It's not exactly the same, but similar concept. And I think for you guys who are a little newer to all of this, traditionally, no one ever thought that these kids with oncologic conditions could just take three hours of therapy a day. It was kind of just like, why would we make them do that? They're already getting all this chemo. Like, they've got 8,000 other things going on. Why would we ever do that? And I think over the years, what we've realized is the longer you wait, the worse they get. And trying to keep them strong, keep their endurance up as much as we can, I think has so many benefits. So I think now in cancer rehab world, we do prehab. So even before they start therapy or start proton or radiation or anything like that, we do a little burst of therapy for some kids. We do it during treatment. So kind of like these kids in the SPRINT program, they might have been on chemo. They might be getting different things. And then post-treatment, there's lots of residual side effects from chemotherapeutic agents that you have to deal with for months and years down the road. So I think probably part of why this group did this article, my guess is, is to just demonstrate that it was safe and effective and there weren't a lot of adverse side effects. Because that's not the common thinking. And I don't think until this article came out that there was much literature to support that, even though across the country, a lot of us are doing these kind of programs. But there just wasn't anything in the literature. So I can say they definitely work. We have a version of it here. It's great to see these kids do this and get stronger. And kids you never thought would ever leave the hospital look great when they're done and after really, really long admissions and whatnot. So I'm happy to answer any questions. Or Shonda, I know would answer questions too. I have a question. Did a great job. I have a question. Sure. For the therapies and I guess treatment done in the sprint program or something like it, how is it distinguished from like an acute inpatient rehab setting? So like what, I guess what's different between the two? Because it looks like this one is before you go to inpatient rehab is my understanding. But I was just kind of curious about that. Yeah. So I can, I'll speak kind of in a broad topic because I think there's lots of different versions of this in the sprint program is just one of them. I agree with you. My understanding of the sprint program. And when we did this article in journal club, kind of what we took away from this is, you know, this probably functioned as a, in a couple of different ways, you know, for those that couldn't maybe come to the rehab unit also, or weren't quite ready, you know, to do the, you know, full rehab program. You know, the one that we have is truly for folks. We have a couple of different groups of folks that we consider for it. But truly for folks that are so medically complex that we as rehab doctors, let's just say should not be managing all of their medical concerns that they have going on. And it's just really from a safety standpoint. They should, we should just not be managing their stuff. And so that's how we run ours. And so for our kids here, they actually do the exact same program as our inpatient rehab kids. They're considered part of our inpatient rehab program. They get the same schedule. They get everything the same. The only two differences are, you know, our group typically for rehab here manages all the medical problems. We're, you know, the first call primary physicians. We are not for this group of kids. We call ours the modified program, you know, semantics. And then they also stay on their like home-based unit. So like they don't come down to the rehab unit. They don't transfer floors. They stay with the oncology or the BMT nurses. And so that's how we have ours set up. And I think there's anywhere in between. So I would just say there's probably tons of different versions of, is it before rehab? Is it the equivalent? Is it, you know, what is it? And every program is probably a little bit different is my guess. Okay. So it's more like their medical conditions and scope of practice for the physician, like directly caring for them versus the physical activities that they're having the patients do. That's ours. I think that I don't know. I don't know exactly for this sprint program. I suspect it might be a little bit of everything for the sprint program. So probably there's some kids that got put in it because they weren't quite, you know, quite 100% ready for inpatient rehab. And there were probably kids that were too medically complex and that's why they got put there. But I think there's probably, you know, if you took 10 programs that have these across the country, I'm going to guess everybody does it just a smidge different. Thank you. Yeah, no problem. I have a question to kind of piggyback off of that, if that's okay. Since your patients are remaining on the unit that they started on, are you having any trouble with like resource limitation with regards to rehabilitative exercises and how do you work around that? Oh, great question. So it has taken us years to get to a better place. So ours is not a new program. We've been doing it for, I don't know, a long time. And there are definitely struggles. I think, you know, we've gotten to a better place. There's still struggles every once in a while. I think, you know, some of our biggest initial struggles were just the schedules and like how different our culture is on rehab versus on the acute medical floor. So like, you know, just an example, like, you know, when you're on the hematology oncology floor, there is no time to wake up in the morning. You kind of roll out of bed whenever you want to. You can sleep until 10, you know, you can do whatever you want. That's not how it flies when you're on a rehab schedule. You got to be up. You got to eat your breakfast. You got to do your thing. And so that, I think, has just taken, you know, tons and tons of admissions over the years and getting more familiar with, for us, it's BMT predominantly. That's our predominant population we do modified with and just getting familiar with those attendings and those nurses on that floor. And they're just used to us and they're used to having kids on modified. I think for us specifically in Cincinnati, the rest of the resource stuff in terms of like the therapists that treat them, you know, the social workers, the case managers, all of those other aspects that come along with an inpatient rehab admission, you know, the way we have it set up is they're just another one of our patients. So they count as our, you know, number of kids. We have a max number that we can have in our program at any given time with our resources that we have. And they're just one of those numbers. We do put a limit on how many of those kids we can have at one time, just because we've found that if there's too many, it gets a little logistically difficult with just travel times with therapists and picking them up for therapies and going to our gyms and that sort of stuff. But in general, they're just another one of the group. I don't know. I couldn't comment on like the Sprint program in particular, how they deal with that. But that's just one of, you know, kind of our experience with things. Okay, thank you for elaborating. Yeah. A lot of good questions, but I'll make sure we got time for our third presenter and final one of the night. We have Jacqueline Spangenberg, third year med student at Louisiana State University School of Medicine here to talk to us today about early sub-threshold aerobic exercise for sports-related concussion. So take it away when you're ready, Jackie. All right. Hi, everyone. So let me share my screen. Okay, so that kind of thumbs up if that looks correct. Looks good. Okay, cool. So like I said, my name is Jackie Spangenberg. I'm a third year at Louisiana University here in New Orleans. If you hear a loud noise, by the way, I'm sorry. That's a streetcar. I live right next to it, and it's the worst. And it sounds like a weird rumble. So I just wanted to let y'all know in advance. Okay, so yeah, I'll be presenting on early subthreshold aerobic exercise for sports-related concussion, and this was a randomized, see, that's it, can you, it sounds, it's weird, randomized controlled trial, and this was performed by Letty and Al. So I thought that before we dove in that we can maybe warm up a little bit with patient X. So patient X is a 15-year-old male who was brought to the ED about one hour after having a head-on collision with another player. After that collision, he was confused, but he could use words okay, he could open his eyes spontaneously and follow commands, but he had no loss of consciousness at that time. He did have a headache and with some dizziness and nausea, but then when he got to the ED, he felt no longer confused and well. His vitals were normal, he's alert and oriented, he had no neurological deficits, but he did endorse some mild tenderness to the patient over the crown of his head. So my question to y'all is do you think that we can diagnose our patient X with concussion? I can't see the chat, so if you could holler out, that would be great. Any ideas? I think some people have feelings about this. Nothing in the chat so far, Jackie, but I'm keeping lookout for you. Okay, well I hope some of y'all assumed yes, because we should be highly suspecting a concussion in patient X. So according to the International Concussion Sports Group, you should really consider a concussion if just one or more of the following clinical domains are present. So that could be if just one or more of the following clinical domains are present. So that could be some somatic symptoms, cognitive symptoms, or just emotional symptoms at that time. Also, sorry, there we go. Also, they could have behavioral changes at that time. So if any of these symptoms are present, you should really be considering moving forward with the appropriate management of the sports-related concussion. So in our patient X, who had multiple of these signs present, we should do something about that. What do you think we should do? I gave some options for this one. Do y'all think we need to image his brain with an MRI? Should we emit him to monitor his ICP? Should we discharge him and just tell him to refrain from all physical activity for a week? Or do we keep him in the ED for a few more hours and then tell him to refrain from all contact sports for about a week? What do y'all think? Any thoughts? I know there could be some thoughts out there. Would it be D? Yes. Very nice. We're going to go with D. So according again to that concussion and sports group, the acute concussion management is a graduated process. We first want to start our We first want to start our patients off with complete rest. That is physical and cognitive rest. Super boring to some adolescents. And then once our patients are doing well, the recovery process is pretty graduated. So we first start them in light aerobic exercise, in sports-specific exercise, non-contact training drills, followed by full contact, and then we can then return them back to the clinic. If any of y'all are interested in reviewing these guidelines yourself, you can just message me in the chat and I'll forward you this paper. They have all these guidelines present. So now that we've gone over this and had a little bit of a warm-up, I think we can dive into our paper. So the first part of the paper, we're just providing a basic definition of what a sports-related concussion is. And according to the concussion and sports group, it's a complex pathophysiological process affecting the brain induced by traumatic biomechanical forces. And as probably a lot of y'all know, exercise often worsens the symptoms following a concussion. Maybe you've had one or you've had a patient that's had one, but like if you exercise to exhaustion after you've had a concussion, often there's going to be worsening of that photophobia, maybe phonophobia, headaches, or dizziness. And so it really, it's not fun to exercise to exhaustion after a concussion. And the reasons behind that, there's a few different ones. It could be autonomic dysregulation, reduced cardiac shock volume, impaired control of cerebral blood flow, all that could be a result of the concussion itself. So that's why for these reasons, the current standard of care is just rest until these symptoms resolve. However, that could give kind of a while for these kids to be resting because up to 30% of kids and adolescents remain symptomatic with concussion symptoms just post the injury for one month. That's a long time. So what they wanted to do in the study was that they said, well, we know that exercise to exhaustion can often exacerbate these symptoms of concussion, but we also know that exercise has a lot of benefits to things like autonomic regulations, cerebral blood flow regulation, cardiovascular physiology. So maybe there's like a sweet spot there. Maybe we can consider that just early sub-threshold exercise, well, sub-symptom threshold exercise training could be beneficial to these patients after concussion. So the purpose was to evaluate the effectiveness of an individualized sub-symptom threshold aerobic exercise program versus a placebo-like stretching program prescribed to adolescents in the acute phase after a sports-related concussion. So the way they did this was that they recruited patients from four different outpatient concussion clinics, and they were looking for males or females between the ages of 13 to 18 who presented within 10 days of a sports-related concussion. And these patients need to have been evaluated by a sports med physician who used the international concussion sports group criteria to diagnose concussion. So as you can see, there's a laundry list of exclusion criteria. If a patient had any focal neurological deficits, they couldn't exercise, or they were at increased cardiac risk. Y'all can read through these, and y'all have a copy of the paper, but there's a laundry list of exclusion criteria that would exclude participants from the study. Once participants were determined to be eligible for the study, and they volunteered for the study, then they had their baseline assessments. That included a history and physical exam, as well as a Buffalo concussion treadmill test. If you're like me, and you have no idea what a Buffalo concussion treadmill test was when you first read this, that's okay, because it's a test that has the goal of assessing when a person reaches exhaustion and then progresses into concussion symptom exacerbation. And when that point occurs, then you measure their heart rate at that time, and that's determined to be their heart rate threshold. The whole idea is that you can then use that value to then determine a safe heart rate. That's considered 90% of that heart rate threshold. But for the purpose of this study, they use 75, sorry, 70% of that value. Once these assessments were finished, they then divided the patients into the aerobic exercise group and the stretching group. The participants in the aerobic group were instructed to perform aerobic exercise for about 20 minutes each day on either stationary bike or treadmill. Or they were in the stretching group where they were instructed to perform gentle but still progressive stretching for 20 minutes each day. Now at the end of each evening, all the participants were instructed to log their daily symptoms on a secure website. Then each week, all the participants were then re-evaluated using the BCTT. And that was just to establish a new target heart rate while the patients continue to recover. So this study lasted until the patients were symptom-free or until 30 days. So that is if a patient was symptom-free at two weeks, then that's when their study concluded for that patient. So that or until 30 days. All right, so for outcome measures. The primary outcome measures was just to measure the number of days to recovery since the date of injury. And they defined recovery as symptom resolution back to normal. Secondary outcome measures included to measure the proportion of participants with delayed recovery. And they defined delayed recovery as congestive symptoms that were present for greater than 30 days. And then they also assessed a daily symptom score. Okay, so moving into the results of the study. 165 participants were assessed for eligibility. And of that, 113 were deemed eligible. And then 57 of those 113 were allocated to the aerobic exercise group, whereas 56 were allocated to the stretching group. Of all those values, some were lost follow-up and some discontinued intervention due to other reasons. So in total, 52 were analyzed in the aerobic exercise group, whereas 51 were analyzed in the stretching group. When we were looking at the demographics between the aerobic group and the stretching group, we noticed that there was no significant differences between those two, nor were there any differences between the original measurements for the Buffalo concussion terminal tests. Okay, all right. So we're moving into that first primary outcome. Time to recovery. So as y'all can see in this Kaplan-Meier, the median score, the median number of days that the aerobic exercise group reached a recovery was in 13 days, whereas the participants in the stretching group recovered in a median of 17 days. This difference had a p-value of 0.009, so that's pretty significant. Then looking at that more, they used a parametric survival model. And through that, they then determined that the aerobic exercise group recovered significantly faster than the stretching group, and that had a p-value of 0.005. So then looking ahead to delayed recovery, and remember, delayed recovery was concussive symptoms that were present beyond 30 days. So at the bottom, you can see that there are two participants in the aerobic exercise group that made it to a delayed recovery, and then seven participants in the stretching group that made it to a delayed recovery. Although the incidence in the stretching group was higher than that of the aerobic exercise group, this did not reach significance. It had a p-value of 0.08. So there was a higher incidence, but this was just a trend. Then if we look at the daily symptoms score, now remember, this was the symptoms that all the participants logged at the end of the day. Of note, all the participants in each group logged the same proportion of daily symptoms every day. So the aerobic exercise group completed an average of 83 percent of the values, and the stretching group completed about 86 percent, and there's no significant difference between those. But when we're looking at this graph, what we can see is there's a pretty much a decrease, a more rapid decrease in the aerobic exercise group when it comes to looking at the total symptom score compared to that of the stretching group. But although this decrease looks to be more rapid, there's no actual statistical significance. All right, so the discussion points. The first thing that they discussed was the safety. Is this safe for us to be prescribing to our patients early in the early exercise in their treatment protocol? And they compared this to a study that looked at a similar program performed in collegiate athletes, who had collegiate athletes that were prescribed early exercise versus those with relative risk. Although the study didn't notice any differences like our study did, what they did note was that there was no lasting impact of possible concussive symptoms that occurred with early exercise. So this study, as well as our study that we're looking at, really kind of includes, hey, this is a safe option that we can be giving our patients, this early sub-symptom threshold early exercise. Then, if we consider the tendency for this treatment protocol to prevent undelayed recovery, we kind of need to consider two things. First, we need to consider that there's several post-traumatic pathologies that appear to be responsible for delayed recovery. That include cervical injury, vestibular or oculomotor dysfunction, traumatic headache syndromes, and oftentimes when a patient has made it to this delayed recovery period, you have to also address these multiple post-traumatic pathologies in order for the patient to fully recover themselves. That can be quite expensive and quite time consuming and often patients can be lost to follow-up because they just don't want to come to the doctor anymore. So if we're able to prevent this delayed recovery period, then hopefully we can prevent the need for additional medical therapies. Also, if we prevent delayed recovery, then we can hopefully get our patients back to full school, back to full sports faster rather than later. Now it's necessary to note that we're not saying that delayed recovery means that we can return our patients to full sports immediately. No, what we're saying is that we can progress them faster to reach that protocol that then graduates them to get to sports faster. So a study is not one without its limitations. One thing that the study did not look at was the mechanisms responsible for the benefits of exercise after concussion. Additionally, the participants were not observed during the prescribed interventions. Nor were they blinded to their treatment. Although they were not blinded to their treatment, one thing that they did note was that they didn't tell the patients which intervention was better. They didn't tell them like, hey, stretching we think might be better. They'd tell them if they think aerobic exercise is better. So the patients were kind of blinded themselves. Also, the patients in each group received the same amount of attention, I guess you'd say. They all were called the same amount. They were all followed up the same amount. So they didn't know if one group was a placebo. They didn't know one group was just not getting the same amount of attention. Also, the study did not assess expectations of benefits. They didn't ask the patients, hey, how do you think this intervention is going to benefit you in your recovery? So that's something that they wish that they went back and they did at the beginning. And then lastly, the study was isolated to the adolescent population. And the reason that it was isolated to the adolescent population, because adolescents have been shown to have the longest recovery period of all populations with the concussion. So those were the limitations. And then last is the conclusion. So in conclusion, this is the first study to show that individualized sub-symptom threshold aerobic exercise treatment prescribed in the first week after a concussion is a safe and speedy, can provide a safe and speedy recovery to adolescents with concussive symptoms. But like I said earlier, please note that this is not saying that you can return this adolescents to sports specific place sooner. Rather, it's just an early active intervention that's intended to improve the recovery of the patients. And then from there, you can then start the protocol to return to place sooner. In the future, the authors would like to perform a larger perspective study that investigates the mechanism of action of aerobic exercise on the concussed brain, as well as determine if prescribed early sub-threshold exercise does in fact prevent some patients from having a delayed recovery. Like I said, in this study, all they saw was this tendency to prevent that delayed recovery. They didn't achieve any actual significance with it. And they're hoping with a larger perspective study, they can see if that whole is true. So that is my presentation. Thank you for listening. And now I will take questions. Oh, I can stop sharing. Sorry. All right. Thank you. Awesome. Great presentation, Jackie. And then Dr. Bolger. Yeah, great job. I think as I was reading this article, this is kind of one of those moments that I get to reflect on how things have changed. And you guys will go through this too, that something you're learning right now in medical school probably in 10 years is going to seem like the worst idea ever and totally different treatment mechanisms. So when I was in your shoes, people would have laughed at you and thought you were doing malpractice if you told a concussion patient to go do aerobic exercise. So even in residency when I was training, our recommendations were three days of rest. Lay in your bed. Don't do anything. Don't use your phone. You can get up. You can eat. But don't do much else other than that. And I think if I told that to anybody I saw now, my partners would not be very happy because we know that that's actually bad for you now to lay there and do nothing. So it's just kind of funny how things come full circle. But yeah, I think there's lots of great studies out there. I don't think we know exactly at this point, like you said, Jackie, why aerobic exercise seems to prevent these delayed concussion symptoms, but it certainly does. We see it time and time and again. So I think for you guys how it translates clinically to me when I'm seeing these kids in consult like after they get admitted to the hospital or soon after their concussion is just reviewing like you shouldn't be a bump on a log for a week after you have this happen. You can get up. You can do chores around the house as long as your symptoms don't become worse. There's certainly goals that we're going to want to get them back to, but they can take walks with their family. They can put the dishes away. They can do other things like that. So I think it's just funny how drastically different this is from 10 years ago, what we were recommending, but all things come full circle. Yeah, it was actually great. Last week I was in a pediatric concussion clinic and I really appreciated how the attending would describe what activities he could do for his patients. Like, imagine it's old school times. We don't have TVs. We don't have phones. Go play cards, go fish, go do something like it's old school times. And I thought that was really great. Did the kids know what cards were? Is that still? I didn't ask. I didn't ask. Do you have a quick question? And great presentation, Jackie. Dr. Bulger, so I've never heard of the Buffalo concussion treadmill test. I don't know if you have. In terms of identifying any of the sub-symptom thresholds, do you know of any other devices that are out there that can measure that? And if you do any sorts of measurements at Cincinnati? I don't. And I, you know, there might be something out there. So don't take my word as like the end all be all, but I kind of read this Buffalo test or whatever the official name of it was. I wonder if it's a little more research heavy and like used a lot in research studies. It doesn't seem to me like something we would do clinically. I just don't, I don't know how we would make that ever happen just logistically. But I think there's a lot of things like that in research, right? Like, you know, you want to ask a question, you want to have an evidence-based way of developing your study. And I think we have a lot of those kinds of things. I think, you know, for us clinically, how that translates into like real practice kind of pearls is, I mean, I'm not going to tell my patients to go monitor their heart rate. I'm going to say, when you start having symptoms, don't do any more. Like that's your, that's listen to your body. That's your cue. And to me that I hope that's probably where the heart rate is and what they're doing and where they're exercising at. But that's kind of our rule of thumb. And so some kids may get to a little more activity, you know, in those first couple of days quicker than others, because they just are not having symptoms as quickly, but that's typically how we translate it clinically, especially in those first, you know, three to five days. Got it. I understand. Thank you. Yep. No problem. Nice job, Jackie. This was great. I'm curious. I know that you mentioned, we don't really know a mechanism for the benefits of aerobic exercise in the acute rehab period, but do you think that perhaps if we, you know, I know we identified the stretching group as a placebo, but do you think there's some benefit to stretching? And if we actually did a full placebo with like no activity whatsoever, that stretching would have actually have been an upgrade over being completely sedentary? It's a reasonable question. I have no idea. I mean, I kind of feel like it's something, so I don't disagree that it's probably better than nothing. It'd be cool to have a third arm, to be honest. I mean, it makes you recruit more patients, but I mean, the fact of the matter is, you know, there's probably a good subset of concussion patients that regardless of whether they seek care, follow protocols, do any of this stuff we're talking about, they're not going to do any of this stuff we're talking about are totally going to get better because that's the nature of concussions for a lot of people, you know, and it's hard to always tease out, you know, who we're going to be, you know, who are those people in that group to begin with, but I think it'd be totally interesting to do something like that. Awesome. So, unless we have any last minute questions. That sounds like a lot. Okay, we're good. All right. So, not hearing any last questions, so I'll go ahead and wrap this up. So, it's a great evening to talk about pediatric rehab, some topic that a lot of us are really passionate about. So excited to have Dr. Bolger here to help us out with everything. Thank you to our presenters, giving three great presentations. I'm going to turn it over to Dr. Bolger, who's going to talk a little bit about the topic. So, I want to thank you all again, and sorry for technical difficulties coming through. Unfortunately, it's hard to control sometimes, but we'll try to control that for next time as well, but I want to thank you all for coming, and thanks for sharing this great night with us. Yeah, thanks, guys. Great job. Thanks for having me. This was fun. Thanks, everyone. See you in May, hopefully. Thanks, y'all. Have a good night, everyone. Bye.

SPRINT program

Seattle Children's Hospital

functional decline

acute oncologic care

physical therapy

occupational therapy

speech therapy

mobility

adolescents

recovery