Hi, good morning and good afternoon, everyone. And welcome to the TCA's webinar for spinal cord injury. This is part five. We have a very dynamic lecture today related to rehabilitation and kids with spinal cord injuries. We will be recording the session and we'll hold questions to the end of the presentation. I'll monitor the chat for any questions. And without further ado, I would like to introduce today's guest speakers. We have Dr. Nathan Rosenberg. He's a Pediatric Physical Medicine and Rehabilitation Physician at Nationwide Children's Hospital. He is an Associate Professor of Physical Medicine and Rehabilitation at Ohio State University. Additionally, he serves as the Medical Director of the Rehabilitation Inpatient Consultation Service at Nationwide Children's Hospital. He attended University of Wisconsin for undergraduate study and University of Vermont for medical school. His residency in Pediatric Physical Medicine and Rehabilitation have completed and at the University of Washington and Fellowship in Pediatric Rehabilitation was completed at Nationwide Children's Hospital. When not working, you might find him running the trails, snowboarding, or planning his upcoming spring garden. Next, we have Laura Rookie. She's an Inpatient Occupational Therapist at Nationwide Children's Hospital. She graduated from Ohio State University with a Clinical Doctorate in Occupational Therapy in 2019. She works primarily on the Inpatient Rehabilitation Unit, treating neurological diagnoses, though also works in the acute care and patient populations, including critical care, trauma, and infant feeding. Laura has achieved her Brain Injury Specialist Certification and has a clinical passion for patients with spinal cord injury. Laura is also interested in exploring use of pelvic floor and biofeedback practices for management of neurogenic bladder and bowel. Additionally, she has a great passion for adapted sports and volunteers as an assistant coach for the Ohio Buckeyes Blitz Wheelchair Rugby Team in Columbus. And finally, we have Tara Grimes. Joined by the Admissions Department of Shepherd Center in 2011, she had previously worked for Shepherd Center as the Occupational Therapist in the ICU and Outpatient Therapy Department. She has experience in all aspects of rehabilitation, including acute care, inpatient, subacute, outpatient, and home health. Tara covers Maryland, Washington, Virginia, West Virginia, Pennsylvania, New York, and New Jersey. Tara received her Bachelor's Degree in Health Science and her Master's Degree in Occupational Therapy from St. Francis University in Laredo, Pennsylvania. Without further ado, I'd like to introduce Tara Grimes. Thank you, Chris. So my lecture, and thank you for having me here today, is coming from, stemming from being an Occupational Therapist and working with spinal cord injury patients, and then transitioning to the role that I am in now, which is in admissions for spinal cord. And I go to a gamut of different levels of trauma centers, LTACs, to evaluate these patients, and really kind of seeing what was hindering them in progressing to the next level of care. So what I hope my lecture will provide for you today is some information about spinal cord injury, these complications that we really see in our spinal cord injury patients, and then how can we overcome those barriers or the challenges, and then progress those patients to the most appropriate rehab level of care. My disclosure statement, no relevant financial or non-financial relationships with the product, services, described, reviewed, evaluated, or compared in this presentation. So objectives for my program is, we're gonna start looking at bowel programs for spinal cord injury, identifying three solutions for maintaining skin health or pressure sore reductions, and then also list three strategies to implement for successful progression to rehab. So when we're looking at the statistics, and these are new statistics that they just came out with last year, have actually had an increase in the patient population that have spinal cord injuries in the United States. But I think this picture is a great representation of what we're looking at with spinal cord injury. Unfortunately, it is mostly males. They are high risk takers. It is, the average age is in the 40s, and it's a diverse group of people. So I kind of think that that picture really represents that. Okay. And briefly kind of just going over the levels of injury. So our tetraplegics, which are cervical levels injury, they're gonna be our C1 through sevens. These patients are going to have limited to no mobility in their upper extremities, and then limited to usually no mobility in their lowers. Our paraplegics are thoracic, lumbar, and sacral injuries. These patients, we consider them ability usually to have upper extremity mobility, but their levels of care and independence also come into play when you're talking about where their actual injury is. And then you hear a lot in the hospitals, these complete versus incomplete. A lot of the times in the hospitals, they will be, you know, C5, Asia A. The complete versus incomplete really is whether they have sacral sparing. So if they have some sensation in their sacral area, and then also it could be a sensory or motor function below that level of injury. So we are seeing a lot of these patients that are transitioning to incomplete in rehab once we do like the actual spot, the Asia exam and the spinal shock and the cord edema has decreased. So incomplete tetraplegia is currently the most frequent, and the last statistics that came out in 2011, and these numbers have really had not changed at all. So, but once again, we're kind of thinking about incomplete versus complete. It's sensation and or motor movement below the level of injuries. So, and over the years, we are seeing more incomplete injuries. I think it really is due to the increased number of trauma centers. They've got proper MD staffing, the care, medications, the medical advancements, and then really early therapy intervention. So what can we do in the acute care setting for a successful progression to rehab? So, and it's the whole team, right? It's not, it's the case managers, it's the therapists, it's the nursing staff, it's the physicians. Can we all work together to get that patient to the next level? So according to Arch Physical Medicine Rehabilitation Book in 2017, having the mindset that they will do that in rehab is not always the best route to take. So preventing complications and starting that quote unquote rehab process early will promote an environment that will make the patient's rehab journey more successful. So let's talk about the major medical complications that we, that prevent a smooth transition to a specialized rehab for an SCI patient. I mean, there's always a gamut of things could go wrong, but these are the things that we see most common in the patients. We're gonna go into detail of the seven most common, and then we'll highlight just a few other ones that we see, but not maybe necessarily as often or as a barrier. So these are the most seven progressive, provide aggressive pulmonary joint. We're gonna prevent venous thromboembolisms. We really need to maintain their skin health, bowel management and bladder management, pain management, early therapy intervention, and infection control. So our leading cause of death in our spinal cord injury patients is going to be pneumonia. It really has a lot to do with their inability to cough, their immobilization, a lot of the times they're in the bed, especially if they're orally intubated and their artificial ventilation and general anesthesia if they've had multiple surgeries. So we're gonna go back to our cervical levels of care. The C2 and above injuries in most cases, they're not gonna have diaphragmic innervation, and they will become, are typically vent dependent. C3s, 4s, and 5s, they can have full or partial innervation of the diaphragm, but they tend to rely on the accessory muscles. So if you see these patients, their whole upper chest body is moving up and down, and that's where they're using accessory muscles and not necessarily their abdomen, their abdominal to be able to get that full breath. And then throughout the lecture, you'll notice the things are in red. Those are gonna be the things that you can do to kind of, to prevent this, or once these things occur to kind of help it move along. So, and then even with our T spine injuries, they still might have some issues clearing secretion. So, you know, a T, there's not full innervation of the abdominal muscles until you get below T10, which is your belly button. So they still have, sometimes it will have that inability to get all of that, the mucus up. So we're gonna be providing good oral care, always swabbing with hydrogen peroxide. We try to keep the patient's head elevated. So early intubation does reduce the sputum retention. So if you have those quadriplegics and they just can't seem to get it up, sometimes it's easier once they're intubated that they can do the suctioning that way. And then tray care is gonna be essential. And then throughout this whole lecture, you're going to notice this one thing that we're always talking about and it's early mobility, right? Out of bed, edge of bed, and then now prone. So we use prone a lot at Shepherd and it, because those patients are constantly just laying on their back or sitting in a position. But, and I think that prone has become a little bit more well-known or, and completed because of COVID. That was the position that we were putting those patients in. So I think that that's something that is going, is really great for spinal cord if they can tolerate in the acute care setting. So we're critically thinking about these patients with their, you know, they're orally intubated for a long period of time that, you know, a lot of those patients they've already had fusion so that they have swallowing and you can lead to some swallowing issues. We tend to see that the C5-6 patients tend, usually will need a trach. Not that they will be bed dependent forever but it just seems to help them, you know, recover better and not have to worry about those secretions as much. You know, we also can take in consideration the mechanism of injury. So our diving accidents, are they coming in with aspiration of water? Our MVAs and our motorcycle accidents, you know, those are a lot of the times are associated with pneumothoraces. Do they have a history of smoking and lung disease? Our second complication is our VTEs, our venous thromboembolisms. So both DVTs and PEs are both forms of VTEs. So this condition happens when a blood clot forms in a deep vein, usually in the leg. Immobility does lead to these clots. We're elevating the legs. We're noticing any redness, swelling, shiny skin, rapid heartbeat, chest pain. But leg pain isn't necessarily going to be a symptom for our spinal cord injury patients simply because they do have a reduction of sensation and pain. So immediately we're doing an anticoagulant regimen. If, you know, if it's not counter indicated, they, some patients will get vena cava filters and they can be removed once they're in rehab a lot of the times. We use sequential stockings are great, but they need to be checked often. And the stockings need to be taken off daily just because we want to make sure nobody gets any skin breakdown. And then there again, mobility and range of motion. And range of motion can be taught pretty early to the caregivers. And it's not only great for the patient, but it really gives those caregivers, mom, dad, you know, family members, wife, husband, a purpose and a little bit more control over it. So our skin health is going to be prevention is key. So just as little as two hours sitting on a hard surface. So if they're sitting on a stretcher or waiting for an MRI, it really can cause a significant pressure injury that can evolve into something worse. So not only obese patients or overweight patients are at risk, but our smaller patients, which bones are closer to the skin actually puts them at risk also. So we're looking at all of those contributing factors and a lot of these patients are also not eating. So the malnutrition, making sure we're getting the correct tube feedings to help with that. So pressure injuries really can affect the patient transitioning to rehab and what level of rehab. So wounds, especially sacral and coccyx wounds will limit the patient's ability to get out of bed. And especially, cause if they sit in there for too long and they don't have the proper weight shifting and cushions that they can increase, the wound will just get worse. And then we don't want to get septic or anything like that. So depending on the size of the wound, it really can limit their choice. So if you say, for example, we have a 24 year old para who now has a stage three or four wound. He might not be able to go to rehab because he can't sit and tolerate three hours of therapy. He might end up going to a SNF. And when you're a skilled nursing facility, they're probably going to receive less therapy. Typically the therapists there are not going to be 100% knowledgeable about spinal cord and spinal cord injury rehab cause that's not their forte. And then really that kind of limits their maximum potential. And it kind of will, you know, with also with insurances, once you go to a lower level of care to argue to go to a higher level of care, like acute rehab can be very quite difficult. So a lot of our spinal cord injury patients are going to be in the ICU. So really avoiding the pressure in there. So shifting and turning every two to four hours. And I know there's a lot of new technology out there with beds and there's the substitution for turning a patient manually, but really there's nothing that really just need to side to side and then padding off as much as you can. And mobilizing in the wheelchair as possible also is great with a 30 to 45 minute weight shifts. And this is just an example of where you're going to hit the most prominent prominences, which is your occipital bone, your scapulas, your elbows are often pretty under looked and then really keeping the skin dry and clean. So if you imagine that you're sitting in a movie theater during a two hour movie, you will shift your weight over a hundred times without even realizing it. But if you're paralyzed, you're not able to do that. So when we're saying, you know, the patient we want to increase their mobility, they're sitting up in a chair, some therapy departments can have like spare gel cushions that can wipe down between patients. So really without like the proper chair and cushion would limit out of bed to in a chair position for two to four hours and really seeing if you can try to incorporate some weight shifts side to side or forward leaning. So the one thing to remember about spinal cord there's going to be a loss of bowel and bladder function and occurs with all of them. Some of it is recoverable and things depending on the injury, but those patients are not typically going to have a bowel movement on their own. And we really, you know, sometimes we see these patients and I'll get a referral and a week or two later and they haven't had a bowel movement. So really initiating that early introducing fiber, you know, that goes back to the tube fees or if they're, you know, regular foods, hydrating and then mobility. Get a move, you know, everything works better in our bodies if we're being mobile and active. So things to remember. So the BCR kind of helps determine whether the sacral lesion is upper or lower motor neuron. And that helps predict the type of sphincter dysfunction that they're going to have, especially with spinal cord injury patients that are complete. So a lot of the times they're not testing for that BCR and it doesn't always give a good indication when you're in acute care because you've got other things going on. But if you're noticing that the, you know, the patient's not having a bowel movement with just an enema or a suppository, they might need a digital stem to stimulate that, the reflux and so they can have a stool evacuation. And then always, you know, we always think of this diarrhea doesn't indicate that they are not back to, you know, have a bowel obstruction. Okay, so most patients with spinal cord injury are going to have some type of pain. Identifying the type of pain can be really helpful to kind of reduce sedating medication. So most common pain in spinal cord injury patients we're seeing is neuropathic and nociceptive and then targeting that proper pain management. So nociceptive tissue, surgical pain, a lot of these patients are having fusions, cervical, thoracic fusions, posterior, anterior, even both at the same time. And neuropathic is that nerve inpatient. So a lot of their incomplete injuries are central cord patients get a lot of nerve pain. So really kind of identifying what that pain is and what would be best pain management for it. So sometimes, you know, if the patient's getting a lot of pain medication and they're kind of snowed and they're really not, you know, the therapist goes in and they don't want to participate, then it looks like they can't tolerate the three hours to transition to rehab. We really want to take that in consideration. So, you know, sometimes talking to the family members and the patients say, what did you take for pain in the past? Maybe Tylenol would be efficient. And then, you know, really great communication between your therapist, therapy staff, your nursing staff and physician, but especially with therapy and nursing and say, you know, just calling up there and say, hey, I want to see so-and-so in an hour. Can you make sure he has his pain meds? Or when did you give him his pain meds if it's a limiting factor to rehab? So infection control really reduces the time that these patients can have in acute care, right? So they have, they get a pneumonia and then they have to be on antibiotic and then you have to wait for them to transition to, you know, or they have to go back on the ventilator. So, you know, an SCI patients, like most patients in hospitals are susceptible to infections, but really we're just kind of looking at these two that we see the most often. So our pulmonary and our UTIs. Pulmonary, cleaning the yonker, maybe using inline sterile tracheas. If you have an encephalator, which basically just pulls the secretions out versus having to go down into the actual trachea. And then urinary infections, really removing that indwelling foley if we can, starting sterile intermittent techniques every four to six hours and reducing the use of adult briefs. I know that when they're having bowel movements and things like that, we wanna not have to clean sheets all the time, but that just breeds infection and moisture and skin breakdown. So these are likely to occur with spinal cord injuries, but they might have less of an effect on a transition to rehab, but it is something to just kind of touch base on. So our bradycardia patients, these are gonna be our high level injuries. They typically will need, when you're turning them, it's a vagal response. If you're doing that, maybe hyper oxygenate them, suctioning before you're turning. And then sometimes these patients do tend to need a pacemaker. The hypertension or hypotension, I'm sorry, when we're bringing that patient to upright, they don't have that same ability to bring their pressure up, especially when they have no mobility below in their lower extremities. So we're using abdominal binders, compression garments. If you can slowly bring the patient up, you know, using tilt chairs to be able to slowly increase that head of bed so that they don't drop blood pressure so quickly. So poikilothermia, it's a lot of, a lot of people kind of, this is a thing that people don't think about, but most patients, I mean, spinal cord injury patients, they do not sweat or shiver below their level of injury. So regulation of their temperature is difficult. So sometimes patients were always wanting a fan on them. They're always warm and they're clammy, or, and they feel that, but they can't regulate it because below their level of injury, they don't feel. And then gastrointestinal, you know, with any kind of trauma, we're worried about GI bleeds and ulcers. So we're initiating methods for nutrition and recommending any prophylactic acid reducers as needed. So dysreflexia, autonomic dysreflexia, we tend to see this more often when you get to rehab, it's post-injury a little while, but it doesn't necessarily mean that you won't see it in acute care, especially when you have a patient that maybe has challenges with insurance and discharge planning and things like that, you might still see this. 90% of the time, it's the fact that the patient needs to have either a bowel movement or a bladder, or there's a kink in their Foley. It is a life-threatening situation. The patient's blood pressure goes extremely high. They will tell you that they've had a pounding headache and they're sweating usually above their level of injury. They become very red and molten. So we're sending these patients up immediately. We're moving in a constrictive abdominal binders, compression garments, and we are doing a bowel, a bladder program, and if that doesn't, we could try a bowel program. So a study from the Neuroanesthetic Critical Care Journal in 2019 found that they followed 42 patients from acute care to rehab. 21 went to a specialized spinal cord injury center, and the others just went to a generalized rehab. And they found, quote, specialized intensive care of patients with acute spinal cord injuries involves the management of multiple systems and incorporates evidence-based practices to reduce secondary injury to the spinal cord and their complications. So patients greatly benefit from early multidisciplinary rehab for a neurological and functional recovery. So these are just briefly look at these slides is just to get a better understanding of our demographics or our spinal cord, how long they can live, and then an exact cost of care. So it's really expensive to have a spinal cord. And the more medical complications that these patients have, the more expensive it becomes for them. So we really wanna make sure that we're maximizing and getting them to the proper rehab so that they can have the best quality of life after their injury. So this quote right here is a study that's conducted with two trials of 20 to 30 patients, one group to a general rehab and the other a specialized rehab for spinal cord. And then a conclusion that they found that the early transition to a specialized center showed increased gains in function, decreased complications, and overall increased quality of life for the spinal cord injury patient. So these are things that you are looking at when you're thinking of a specialized spinal cord injury rehab. These facilities are gonna have adaptive technology and advancements in technology, really having expertise, staff, and spinal cord injury. They're treating a higher volume of these patients. They have peer support, family support, counseling. Rec therapy is a huge aspect at Shepherd, but it also is a huge aspect at other facilities to really kind of show these patients that they're not only, you know, working on the physical and occupational aspect of it, but they're acting things that they'd love to do before. Can we do that again? So what's the family looking for in rehab? Is it important for the, what's important to the patient? So sometimes the best place could be right down the road and sometimes it is out of state. So giving the families the knowledge to do their own research and help them to narrow down what rehab might be best suited for them. So any of the secondary complications can increase their stay. We saw that, the cost of care, and then also their independence. So how can we work together? And so the core, a lot of these times is working with your case managers and then kind of reaching out to each discipline in that team to reduce those complications and find solutions for that. So we're breaking through the different barriers. We have trauma rounds typically in our acute, in our trauma centers. You know, the full team engaging with the physicians, the therapists, and then, you know, identifying, okay, wait, this person is supposed to be transitioning, but we're noticing this. And then, you know, if everybody's on the same, is in the same place, we can work on that and then hopefully get them next, the next, to the next level of care. So talking early with the families about rehab and encouraging them to do their research, right? Educate their families and the patients on low-cost care, low-cost care, and the patients on local and national resources that can help with their questions and guide that rehab process. So meeting with the families, starting that discharge planning early. Most spinal cord injury rehabs, and just rehabs in general, are gonna wanna discharge plan upfront, you know, talking to them about that. What does that look like? What would the transportation look like? Doesn't necessarily mean that it wouldn't be covered, ground, air, sometimes there are, you know, different scholarships and things like that that can be helpful for those patients. And these are some resources that we have and that we provide for our families that they can go and look at. There's great information on the Christopher and Dana Reeves Foundation and the model systems, because a lot of patients will say, I wanna go somewhere that concentrates on spinal cord. And one of the best things is to kind of reach out and look at that spinal cord injury model system. They can kind of narrow down their choices. And this is a spinal cord injury resource. It's in layman's terms. We worked with the Christopher and Dana Reeves Foundation to develop this. It is for patients and families to kind of navigate this whole crazy process of spinal cord injury and their rehab process and transitioning. So good layout for references. And I am going to turn it over to Dr. Rosenberg and Laura. And Laura. I'll go ahead and just introduce like our hospital in general for anyone who is not aware of Nationwide Children's, but neither Dr. Rosenberg or I have any financial disclosures to report. Within the presentation, there are a lot of links just to help illustrate some of the items that we use, but this is not an endorsement of any of those specific products. Just trying to shed some lights on those. Overall, we're going to discuss early caregiver involvement and training and how to support them. Tara provided some really nice insights and foundations to that. And our programs are very in line in promoting those as important goals. We will next just identify some potential treatment areas long-term specifically for the pediatric population. And then summarizing some complications from spinal cord injury, again, specific to the pediatric population. There are several handouts, the examples of handouts that we use with patients and families in this presentation. We love to share our resources because specifically for PEDS, there are so many fewer resources, but please, if you are going to reproduce any of these, we just ask that you contact our EBP coordinators for permission. And then at the end of the slide deck, there's also my email. If you do have questions or would like to see more of that information, please feel free to reach out to me. But just to give a little bit of insight, Nationwide Children's, we're a level one trauma center and we have several satellite locations around Ohio with numerous regional hospital affiliations. And we have grown our network into another hospital system in Northwest Ohio. And consistent with our average service provision, in 2022, we treated patients from all 50 countries, sorry, all 50 states and 45 countries. Tara already gave an excellent overview of the potential sequelae following spinal cord injury and all the complications that can arise from that. This definitely is not an exhaustive list, but as she mentioned, the neuropathic and skeletal pain, some autonomic dysfunction and dysregulation can be limiting factors to progression through acute care and rehabilitation. And then thinking about really heavily considering pressure from the very beginning, even in the emergency department, as she mentioned, being on a stretcher or a gurney for hours can actually set up a patient for deep tissue injuries that almost progress from within and might not show themselves until later through their rehab journey. So just being mindful, incredibly mindful of those from the beginning. There's a slide I made right there. So my role here is to cover the part of pediatric specific things. I think there's a general thought of spinal cord injury in humans and people, and children are not just small adults in some situations. And so I thought up a few things that are different in kids, and I'll talk about those. So here's a list. One of them is scoliosis, when I will get into the details of that and the greater risk in kids. Talk about seating briefly. Spinal program and independence and timing for that, knowing that that might be different for a one-year-old. Deep vein thrombosis related to age and how an ASIA exam would be done on a young child versus an adult. So starting with scoliosis, it's fairly uncommon in adults spinal cord injuries. So we don't see it a lot. And a lot of that is because of growth and growth is what often generates a scoliosis. In adults, it's quite uncommon actually once those growth plates have closed. On the complete other hand, in children under the age of 12, it is nearly universal that they will develop a scoliosis in the areas below their level of injury. The exception here is with not only incomplete injuries, but quite incomplete injuries like ASIA-D injuries. A lot of studies will give you a 100% rate. And that's an interesting thing to note with the scoliosis because 100% is a big number and very rarely does a study show that, but then some samples at 100%. So for our side, it's anticipatory guidance. Early on in spinal cord injury to say, doctors don't predict the future, but here's what we typically see. Fusions and growing rods are very common in surgeries. Excuse me for the poor sentence written there. So these are quite, quite common. The growing rods have been a really nice technology lately that we've been able to use and now they're magnetic growing rods. So we don't have to do surgeries to make them grow. Though fusion rates are quite high. So here's something to take home with you. If it's that frequent, why not have it be part of anticipatory guidance? And so my answer is, why not? I don't have an answer, why not? So it's something I bring up early, knowing that families often do have an overload of information. So it's something we say, this is something we'll be keeping an eye on, or if they want a ton of information, we provide it. So seating, the biggest thing to think about, step one with seating is that kids get bigger. And the chairs do get bigger, but they get better differently. And so typical US insurance will pay for a new chair every five years, unless somebody grows so extensively out of a chair or has a change in function that they can't effectively utilize the one that they have. So as we start thinking about seating, I think I remember in residency, doing an adult residency in Seattle, that you look at somebody with like a mid-level parapheresis and you say, okay, how quickly can we get you in an ultralight manual wheelchair? Yes, it's true. And then in pediatrics more, it says, okay, what do we think about if you're an eight-year-old and we do want you to be an effective person who propels a manual wheelchair, for example, but we've got to think about what that chair is going to do for you when you're 13. And so there's a bit of a difference there in how we think. Moving on to bowel program and cathing, there was an old school thought that a lot of kids, the majority of kids are potty trained by age three, so start the bowel program at age three. And 15 years ago or so, that was how it was taught to me, at least. And that was the old school. The new school here is if you got bowels, why not aim for continence and complete emptying? So, I mean, if you can do it, why not do it? And so that is the approach, complete injury and complete injury, is can we get to a point of continence? And as Tara mentioned, the thought about the risk factors of folks being in diapers is true for all skin and all spinal cord injury. And so that's something that is our typical approach. And yeah, get creative. Tara also mentioned the difference between upper motor neuron and lower motor neuron bowel, as in is there reflexive bowel or do we have to use enemas to evacuate? Also a consideration in kids in these settings. It's wild to think that a child that can go into the bathroom and pee on their own is also a child that can go into the bathroom and cath on their own, kindergarten, first grade, especially for the young and mature ones. However, they get really good at it. And so it's a doable thing. I think when you're setting goals, you need to look at the kid in front of you and look at the parents in front of you too and think about that. But I wouldn't set a specific age. I don't think there's like a specific age where kids should be cathing themselves or not as much as looking at the kid themselves. Yes, are there kids that self-cath in kindergarten? There are, there are. Deep vein thrombosis. Here, let's enter a world where we have basically no data. And here, I'm going to tell you about something even though I don't really know beyond anecdote. We don't have a great data about pediatric spinal cord injury, deep vein thrombosis, with the exception of the fact that we're pretty sure that the rates are lower before puberty because there are hormonal changes that put folks at risk for deep vein thrombosis. We still often have a chemoprophylaxis, so enoxaparin, as the standard of care because of the morbidity that does come with a deep vein thrombosis. Although we also, at the same time, there's one hand and the other hand is where we acknowledge that the majority of deep vein thrombosis still are catheter-associated even in spinal cord injury in the little bits of data that we do have. Moving on to the Asia exam. So the Asia exam is something that takes time and has a person's attention too. And we're asking a person to draw a distinction in certain sensory aspects. And also to manual muscle testing, which is not really something we expect from a kid under the age of six or seven very well. And so it's not as easy to get an Asia exam in a younger kid. I think an important place to start is also in trust because if you show a kid something pokey, they're not going to want to play along anyway. You show it to an adult, they say, I can handle it. You show it to a kid, maybe not so much. So step one, make a friend, make sure you know their favorite color, make sure you know their favorite hobby and make sure you know their favorite fruit is say, pomegranate, for example. And then you start calling the kid pomegranate for a week straight. That was fun. So have fun with it, especially the parts where you can have fun, where you have to ask a kid about their sensation and maybe even bring in the rewarding aspects of it. Coming back to the child, there's the child relationship. There's also that parent relationship too, because I think parents start to realize that there are some prognostic factors that come along with the Asia exam. And the parents, as we are parents, those of us in the audience, parents too, we think about our kids and this is a huge thing when someone tries to predict their future. And Asia exams are pretty good prognosticators. And so parents will say, this is memorable almost every time, traumatic for some, both for others. And so a conversation with parents about what an Asia exam does and what it doesn't and whether it actually impacts the future. I don't know if it impacts it as much as it informs it. But that side of compassion, I think, is a little bit more necessary in the pediatric side, but also imperative in the adult world. Also worth noting that sometimes I just can't get an Asia exam. Have to accept that. And you do your best approximation of an Asia exam and see if that can inform the situation. Okay, so up next, we're going to, I'll kind of give you a summary, so to speak. Our clinical therapies department, a subset of us did an evidence-based summary and recommendations review in 2020 of literature in various treatment areas based on our clinical questions at that time. So we won't unfortunately go through all of that research to support what kind of what the rest of the presentation might summarize. And we did this not to necessarily serve as a comprehensive clinical practice guideline because we actually want these standards to be continually changing and evolving and progressing, but more so utilizing the literature to guide what our most pressing treatment questions were, specifically for pediatrics. And unfortunately, a majority of the evidence we came across was meant to be utilized for the adult population. So just taking that into consideration, as Dr. Rosenberg said, kids are tiny adults, but in so many ways, they are not tiny adults. And so we can basically make a blanket disclaimer that the results should be interpreted with caution that we need more large-scale pediatric studies, but we were using what we know to try and figure out what we didn't know and just globally incorporate these best practice techniques into our standard of care, even more so than what we were already doing. And so thinking about it from this three-pronged approach, definitely taking the clinical research piece of helping guide our practice, but knowing that that is quite limited right now. So then taking our clinical expertise itself and really collaborating with our other stakeholders as well, that includes the other disciplines outside of therapies, and then definitely the patient and their family and taking into account their preferences and experiences. We have a very robust multidisciplinary team at Children's, and I would say we're very fortunate to have that. And as Tara presented, and as we all know that spinal cord injuries can be so very complex in terms of all of the different facets of treatment, educational areas, and this presentation is really just a fraction of the needs that need to be addressed in this population. But thinking about even more so with pediatrics, how do we need to meet the patient and family or caregivers where they are in terms of their educational level, as well as their having trauma-informed care? It definitely is one thing to experience a trauma as an adult and see your adult peer or family member go through a trauma, but being a parent witnessing your child go through a trauma can just have such a heavy impact on how they're able to participate in that child's care from the beginning and how that's gonna evolve over time. On our rehab unit, we have weekly psychosocial rounds in addition to medical team rounds that we are all a part of, and you can see all of the disciplines listed. And I would say we are having daily conversations with one another of how we can support one another's goals within our own sessions to ultimately progress the patient and family towards their larger goals. And then, oops, I'm so sorry. And then, really, our medical team is kind of serving as that, of course, like prognostication and medical education surrounding the injury, but we really work with them collaboratively to discuss, like, how medications and pain management may be impacting the patient's participation in our therapy sessions, and then vice versa, how our therapy sessions might be impacting what we are seeing medically. And then, we are collaborating with the physicians, with the nursing staff, with our child life specialists to support some of these more complex facets of spinal cord injury care, for instance, like calving or like bowel and bladder management, because that can be very, it's foreign to anybody, but incredibly foreign and difficult to understand and abstract for a child. And so, really trying to provide developmentally appropriate care as therapists, but working with the rest of our psychosocial team to do so for both the patient and the family. So, really focusing from an early, early, early standpoint, this can be starting in the ICU. We're fortunate to be, our rehab unit is included within our hospital tower, and so sometimes our rehab therapists are the ones seeing the patients early in the ICU. But just from the beginning, we kind of developed a skills checklist that almost broke down for our therapists, and then if we felt like it was beneficial for the family to see, broke our treatment down into phases to serve almost like a roadmap, of course, not trying to predict the future, but more so showing them how our care is going to build across the continuum of their journey. And so, a few areas that we are going to talk about more, but that we definitely focus on pretty quickly are any dermal medical equipment or adaptive equipment use, definitely early positioning, joint protection, any early splinting, getting the patient and family involved as soon as possible. They're going to be the most consistent people in that patient's care, and then doing what we can from a nursing and therapeutic standpoint to support them. Trying to think about seating and equipment evaluations early, and maybe that doesn't mean that we are doing those evaluations, but as Dr. Rosenberg said, for instance, if scoliosis, if we know that it's probably going to happen at some point in their life, evaluating what equipment they're using even as a loner and teaching them the proper positioning and compensatory techniques to avoid that as much as we can or minimize that as much as we can. And then we also have a seating clinic that is completed on an outpatient basis, and so if we think that patient's going to evolve further, are we actually holding off and getting them a loner chair to utilize until they can get to the seating clinic, maybe when their injury has evolved just a little bit more, evolved and stabilized? And then how we're supporting pressure injury prevention, one tool we do utilize is pressure mapping, so we'll talk about that later. This is very small, even in your handouts, it's very small, and it's really not intended to be read thoroughly, but just to give you an idea of our roadmap or our phases of the progression that we might work through with a patient, and it's highly likely that we might not progress through everything on this checklist, even if the patient was appropriate for everything on the checklist. But breaking it down into kind of bed-level positioning, and then as soon as we can, working on tolerance to upright positioning, whether that be at the edge of the bed, a tilt table, a stander, seated in a wheelchair, of course, and then slowly progressing our active movements or using what we have and capitalizing on it that day for the patient. And then thinking about how can we at least get some advanced skills started, what are advanced skills for a patient based on their level of injury, and what maybe we need to provide guidance on to the patient and family of, hey, we might not be able to address this now, or I'm not quite sure that we're ready for this, but it's going to be really beneficial or really important for you in the future to consider X, Y, Z. So the checklist I just mentioned, that was primarily maybe to give a guide for our therapists, and as I said, if we felt like a patient or family was appropriate, we could tailor it and show it to them. But more often than not, we have shifted to some other handouts for our actual caregiver education. So as early as we can, providing like a bed positioning and wheelchair positioning handout that can be helpful not only for patients and caregivers, but definitely for bedside staff as well, maybe who aren't as familiar with spinal cord injury. For them to refer to and have support so that we're not making assumptions about what they, what we know to be true about providing best positioning for these patients. We also developed kind of a comprehensive caregiver checklist for patients prior to when they discharge from rehab, and we'll go through that in a little bit. And then just doing what we can to get their buy-in early to any adoptive equipment or durable medical equipment that we feel is appropriate. And really just not counting out a child. So as Dr. Rosenberg mentioned, if a kindergartener can cath, I don't care what age they are, if they are showing me signs that maybe they're interested, maybe they're not completing everything by themselves, but we will get them as involved as they can be in each area of their care at whatever point that we feel is appropriate. So again, these aren't really intended to be read, but the examples of those handouts that I mentioned for bed positioning and wheelchair positioning will highlight information, leave patient-specific comments, and literally just tape it up in the room so that even if a patient can't necessarily advocate for their care specifically, maybe that's based on their age or their respiratory status or their cognition, we can at least have a visual that they could potentially point to or that their family could reference or have the staff reference. But as much as we can, as young as we can, we are teaching those patients about all of these really foundational and critical prevention strategies and skills that they're going to need throughout their lifespan as a person living with a spinal cord injury. The checklist is much longer than this, but this is just a snippet example of what that caregiver checklist might look like, and we'll individualize this to a patient or a family based usually on their level of injury or where we think we might get to prior to a discharge. But we have found a lot of success recently in this I do, we do, you do model. So I do it as a provider. I am providing that education, demonstration, handouts. I'm providing that to you, and then we're doing it together and using a coaching model as the therapist or staff. We're providing that in the moment coaching to the family, and that would be the we do. And then the you do is the patient or family completing that themselves. We do try to get two caregivers trained over the course of the patient's stay, but of course, any of this can be also completed by the patient if it's appropriate. So for instance, some things on the checklist include bed mobility and positioning critical, but then also how to help them get dressed. And for the patient, if you can't do it, how are you specifically describing to somebody else how you're doing it? And that can be a really challenging task for even teenagers, but then the younger patients as well to come up with those specific directions, especially when either a parent or a caregiver, they're a child, it's their job to take care of this child. And so oftentimes, it almost has to be supporting the caregiver in stepping back. Like, of course, you know what to do, and you're being a great caregiver and wanting to help your child, but we don't want them to learn this have the sense of learned helplessness, and so really as young as we can getting a patient to advocate and be vocal about their own care. So some considerations with durable medical equipment is thinking about their bowel and bladder regimen. Is it appropriate for them to be on maybe a one-time-a-day bowel regimen? How often are they being cath, and are they appropriate for a shower routine? Whether that be from like medical clearance, if they're receiving ventilator support, we can due to infection control not shower them within the hospital, but maybe we are providing that education if we think they're going to wean, trying to help the family make those connections of how pieces of durable medical equipment might relate to multiple ADL tasks. Thinking about their postural endurance and just their posture in general, how much capacity do they have from a neurologic level of injury standpoint? How much could they assist? How much support would we expect them to need, and then how does that change over the time that we're asking them to be up for a task? Considering their physiologic stability, specifically with orthostatic hypotension in the shower arena, TED hose and ab binders are great supports, but to get a thorough clean, those do need to be taken off. So do we need to use something that has more of a tilt function or even more of the ability to be positioned more flat initially and progressing even through the course of a patient's stay? Thinking about their balancing and repositioning needs and what supports they might need there, whether that be built into the chair or from the family or caregivers being the bedside staff, and how do we as the therapist need to coach them in providing that hands-on assistance? And then, of course, considering their pressure needs, which we'll discuss here in a little bit again. As far as adaptive equipment, I could probably talk about this all day being an OT, but just considering, are we working on compensation versus remediation? And sometimes we have to be as cognizant as we can and compassionate as we can in guiding families towards one or the other based on their neurologic level of injury and what might be more feasible or realistic for that patient to achieve in a shorter amount of time. Oftentimes, I will encourage families, you know, I can't tell you what can or cannot or what will or will not happen in the future, what we'll be able to do, but right now, let's use what we have and let's figure out ways to get your body repetitions in reeducating itself and considering it like a piggy bank. We want as many coins or as many repetitions of an activity as we can get to fill up your piggy bank or to regain movement. And so, how are ways that we can do that? And sometimes that does include using equipment for now and then trying to work away from it as we can. Thinking about the task demands and the time constraints, especially in the context of a family. So, and that goes in with patient and family goals. Maybe we think that they could do more of an activity or be more of an active participant or accomplish more percentages of self-feeding in a meal, but if that patient's going to go home and they have four siblings and two of them need to get to a practice and we're trying to get dinner done so that one parent can help with the bowel program, sometimes that family's priority might be just getting the task done. And so, we have to be understanding of that as a therapy staff and from a rehabilitation perspective that we try to give as much education and encouragement as we can, but ultimately the family does still have to live their life. And so, just coaching them on how that might change over the course of their injury. And then, assistive technology, we do have trials of various low-tech assistive technology like SIP and PUF call lights and touch switches. A few options for higher tech technologies, such as eye gaze devices and voice controls. But ultimately, it does come down to the family's acceptance of this. Sometimes the patient or family, they just might not be ready to explore or accepting of the fact that this might be a scenario that they may have to utilize long-term. They might not be ready for that. And so, they may identify higher priority rehab goals that were, so we're just providing them the exposure and then working more on an outpatient basis to explore these other options, potentially when the family is ready. So, pressure mapping, this is one tool that we are fortunate to utilize. And I say a tool because it is just that. I utilize it primarily as an educational option. A lot of times, even for the patient themselves, but for the families and caregivers especially, so that they can understand why it is so crucial. Have that real-time visual of why it's so crucial, these pressure relieving techniques that we are teaching them. So, we can see in this example, the patient was upright on a rolling shower chair. The patient did have a high-level spinal cord injury, and the shower chair did, they had a backrest, but it did not have lateral supports. It didn't have a tilt feature, and they had to be up for their bowel program for an hour. And then every other day, they were doing an additional about 30 minutes right after their bowel program in the shower. And so, using this to illustrate to them, hey, for this patient, you, we are resting so heavily, based on their muscle imbalances, so heavily on the right ischial tuberosity. That's what's lit up red in this photo. We are resting so heavily on there, the combination of water or potentially skin shearing slipping around the seat in the shower, that is going to cause a pressure injury most likely at some point. So, we needed to find other options. So, using that, again, in real time to explore other options that we had available to us, so adding some fluidized positioning pillows under their bottom did help in the short term, but we felt like we could do better. And so, then using that maybe to explore some of these more, the higher end or higher support features of durable medical equipment like a tilt and space shower chair. So, instead of being upright, if we can tilt that patient back, we're using an air chamber pressure relief cushion, so like a Roho toilet seat cover, and we could see that, yes, there is going to be some pressure through the ischial tuberosity. That's what's green on this photo, but we are all going to have that. And so, we're trying to minimize that as much as we can, and then doing really diligent pressure relief strategies to offload even those areas while the patient is up. So, as Tara mentioned, a similar schedule, like every 30 minutes, doing a one to two minute pressure relief, changing the position, and then allowing blood flow to come back into that area. I left this in here not because we're going to go in depth into the spinal cord levels, but I really like this visual to illustrate that oftentimes muscle groups are innervated by multiple spinal cord levels, and so more often than not, we might be asking a patient to complete an activity when they only have partially innervated muscle groups, and if we're asking them to complete that activity repetitively over time, are we setting them up for injury in the future, or maybe is that the reason it's not quite as successful, and what do we need to explore from either adaptive positioning or adaptive equipment to make it more feasible for them? So, that's there for your reference. This slide, this could be a totally separate talk, so we are not going to spend a lot of time on this, but just to touch on the goals of inpatient versus outpatient therapy. So, on our inpatient rehab unit, our focus is really on the transition from this very catastrophic injury, this very dramatic life change to how are we going to, like, live and functionally survive with this spinal cord injury? How are we going to help the patient and family do this? Building those foundational skills for the patient and family just to exist in the context of their spinal cord injury, and then making them aware of opportunities that might exist as they're continuing to progress, really encouraging the family. We use the term rehab targets, not rehab goals, because we don't want to set the precedent that we are done working toward whatever that goal is when they leave rehab. So, we use rehab targets to set more realistic expectations for a shorter timeline to support maybe the end goal of the patient, whatever goal it is, that they might, it might be more appropriate on an outpatient level. So, while we do incorporate things like activity-based therapies and functional, like functional electrical stimulation and supported standing and treadmill training if it's appropriate, just encouraging the families that this doesn't stop once you leave rehab, and you're going to continue to evolve. Again, considering splinting and the role that it can play early on in a patient's admission and change throughout their recovery, and thinking about are we going to, how do we need to preserve the joint integrity and the joint range of motion? And then, thinking about what's available to provide or promote function and then provide any compensatory strategies, one adult study that we came across did report that biofeedback demonstrated more effective tenodesis, demonstrated to be more effective than a tenodesis splint for functional tenodesis training. But knowing maybe that's not always feasible or available to a patient, and how are we still going to get these tasks done? Maybe great, a biofeedback unit is going to be awesome for a therapy session, but we still would like the patient to be getting those repetitions or those pennies in their piggy bank while they're self-feeding themselves lunch or dinner or whatever it is. And so, utilizing those compensatory splinting strategies to help occupational performance in those areas. We will just breeze right through these, but they're a part of your handouts or reference. And then, really, really heavily considering prevention as much as we can. As providers, we know that wheelchair users, manual wheelchair users, and patients with higher level spinal cord injuries in general, they're at risk for overload injuries. because of, remember that graphic that we saw with only partially innervated muscle groups, we may be working with an unstable shoulder girdle, but we still want to teach them how to complete these functional tasks like transfers or not complete, but maybe assist or assist their caregiver. And they will have to work within the context of this for much longer than somebody who sustains their spinal cord injury later in life. And so focusing really heavily on the foundational areas that are listed in this slide, as well as utilizing, you know, home exercise programs or handouts for the patient and family to also support themselves as they maybe are on a weekend from rehab or after they discharge. One article that we came across was the Strengthening and Optimal Movements for Painful Shoulders or the STOMPS protocol. And we have found that this is pretty easy for patients, no matter their age, to understand. Sometimes it does require modifying that rote exercise into a more functional activity to get their engagement and participation. And just thinking about how are we going to help strengthen the accessory muscles or that shoulder girdle to be a little more stable when we are asking them to participate so functionally in their daily lives. Some more opportunities for specific intervention areas. And then one, another area that we do focus on really early in a patient's admission is their respiratory management. I apologize again, this slide not necessarily meant to be read, but is something that we were able to formalize more after we did this literature review. But getting the patients and families as involved as we can as soon as we can in things like assisted cough, so like manually assisted cough, in breathing exercises and breathing techniques to support their either capacity for functional recovery or support their just respiratory health and status in general. We have been utilizing abdominal FES and like a resistive respiratory device training. And those literature articles are listed here, but if you do have questions on that, please feel free to contact me as well. Functional electrical stimulation could be seven different talks in and of itself, but these are just some units that we have here at Children's. And then part of our literature review was we were running into difficulty in really capturing or sensitively describing a patient's progression in the context of their spinal cord injury. We use the WE-FIM as the pediatric version of the FIM at our facility for all of our patients, but we were struggling to, for some patients, identify change from week to week, even though they were making very functional and positive changes. So what's listed in these slides next is absolutely not an exhaustive list of what can be utilized for a patient with a spinal cord injury, but are things that definitely were themes in our literature review. And so I just wanted to call out a couple of the pediatric specific measures. And so these were a little more, they were modified in a way to be reflective of maybe where a patient is developmentally. You know, if a patient's four years old, they haven't even developed some of the skills that would be tested on another measure, and so we don't want to discredit them for not even being able to do that if they were a typically developing peer. And so some of these measures were either, one, modified to accommodate for that, like our first one, or the second outcome measure, we have actually started to incorporate this because it has been just really user-friendly, qualitative, sorry, patient-reported or family-reported outcome that can be a little bit more sensitive than the WE-FIM that we were utilizing in tracking change from week to week or from admission to discharge. And so what often is not considered or what may be a little lesser considered in the adult population is passenger safety because, you know, maybe that patient can just get in a regular vehicle seat or they're going to be utilizing wheelchair tie-downs or medical transport, but for a child, none of that may not even be appropriate for them in their age and their size. And so we work with our certified passenger safety techs to identify if a medically-adapted car seat is needed or if we can utilize a commercial car seat and then working with the patient and their family on the transfers in and out of that as that transfer might look very different than how it did prior to the injury. Supporting developmental play as much as we can, and we'll go through a couple examples of that later, but sometimes there are patients and definitely siblings who are scared to interact with their child who has sustained a spinal cord injury, especially if it's a really high-level spinal cord injury, and how different that looks from prior to injury. And then we, at our facility, we have school reintegration meetings to help school providers understand all these unique needs of a spinal cord injury and how can we support that patient in getting back as quickly as they can to their peers, interacting in a developmentally appropriate environment, and so making recommendations in these core areas for the patient, their school staff, and their family to know what just is possible. With the Go Bag, this would be like their emergency kit if they were to need an extra set of clothes or any of the supports needed if they were to have a medical event like autonomic dysreflexia, for instance, and how that would be supported. These are just some examples of some devices that we can utilize from a passenger safety standpoint. These, best down at the bottom, they're positioning harnesses, so we still utilize them with the car seatbelt itself, but they provide really a very hefty amount of additional postural support because riding in a car can be incredibly taxing when you do not have the muscles to be able to oppose inertia and velocity changes and braking, and so using these when we can, and of course, if we need to utilize medical transport or if the patient and family can accommodate being transported with wheelchair tie-downs, we will do that as well. And so then, these are just some very low-tech examples of how we supported this patient that this example is of. They actually had a high cervical-level spinal cord injury and had really no movement of their upper extremities, a little bit of shoulder shrug, but how we were able to engage them in developmental play and then exploring how they might reenact that or incorporate that at home, and so we got them a piece of adaptive equipment that had a high-low base, so they could be up high maybe for mealtimes, and then that base could just transition them right down low to play with their siblings at home and worked really heavily with the caregivers on how they could manually like physically assist and support that engagement while also trying to support independent play as much as possible because we know that is so crucial for a child's development. And then just thinking about the plethora of post-discharge considerations, and so we work closely and collaboratively with our outpatient settings, wherever our patients do go, to provide some insight into where they are now, but maybe providing some core areas that we feel like they're going to need more support in as they continue to go and exist with their spinal cord injury, and especially as they age. So thinking about things like their body image and how that's going to change over time or over puberty, and how their nutrition needs do change after a spinal cord injury for anybody that changes, but especially how can we help support those foundational choices and routines surrounding feeding early in a patient's life so that they are continuing to live well with their spinal cord injury as they age. Again, thinking about puberty and sexual function and how, as medical providers, there are more support providers that might be providing guidance, but we might not always know best because we're not living with it, and so can we get a peer mentor or a support group connection happening for that patient? Bowel and bladder management is something that we have really been shifting our focus on a little bit more when we can using the, we have an external electromyography unit or a biofeedback unit. We've been using that on a small subset of patients with incomplete spinal cord injuries that we deem appropriate, but again, this might not be something that we can spend a lot of time on during inpatient rehab because we do have that whole caregiver support checklist that we need to get through and some other priority areas, and so just being aware that this might be something that could evolve over time for a patient, and so being aware of your practitioners, like an OT or a PT that may be trained in pelvic floor reeducation in the outpatient setting, but of course, the research to support this within spinal cord injury specifically is so incredibly limiting, so we're working on putting a little bit more literature out there. And some other very, very, very important post-discharge considerations, and I say post-discharge because it is likely things that we have already discussed on rehab, but, or while the patient's been admitted, but they are getting so much information in such a short amount of time, and so continuing to support these as the patients and families get home and they start to live within the context of their spinal cord injuries, they might say, oh, I never learned that when they 100% did, but they just can't recall it anymore because they had to focus so heavily on something else, and so getting patients involved in potentially vocational rehab or higher education, adaptive sports, if it's feasible for them, and then driving when they become of the legal age involved in driver rehabilitation programs. But these are so important, I wish we could spend more time on some of these skills. And then the next few slides, these are just for your reference. Some resources, not an exhaustive list by any means, but when I attend a CEU, I really like grab and go things that I can just start to incorporate. So we do hope that this is, these are some of that for you to be able to, many of these Tara did call out in her presentation as well, but just some like patient facing resources. And then a few pediatric resources, the 180 medical specifically is pediatric tailored activities surrounding calving and bowel management. Some resources specifically regarding home modifications that we do try to initiate education upon as soon as the patients enter rehab. And then just some prime takeaways of some treatment areas that can be focused on in the pediatric population. I'm going to go ahead and maybe, Chris, if you had some questions so that we can start jumping into questions, I'm going to turn it over to you. All right, thank you so much to all our presenters today, that was an excellent discussion and very insightful. While we wait for any questions to come up on the chat box, I did have some come to me while we were going through this, I'm going to start. First of all, I have you, Laura, with you. I mean, I really like that idea of the caregiver skills checklist, the I do, we do, you do. Is this used for all ages and all levels of spinal cord injury? And is this also given to the patients and families to be able to use as home as a checklist? Yeah, great question. So we do try to incorporate it across all ages, but definitely at minimum for the caregivers themselves. And we'll post up in the room. What was shown was really some of our therapy focuses, but this does include the checklist, does include nursing tasks like potentially a tube feeding or catheterizations or trach care. And so it really is a comprehensive list and it can be really overwhelming for families to be presented with this and say, we want you to be able to do all these things before you go home. But having that like I do, we do, you do breakdown can be really comforting to them to know. I don't need to know all of this immediately, but we have had some really good feedback on just having that visual. And then we've even started binders of things that, yes, to your point, like we'll just send this home with you, like for the bed positioning, you've shown us you can do it. But here's your handout that we've been referencing. So if you have another caregiver that's coming in, then you're more empowered and feel supported in teaching them as well. Well, that's excellent. That's really excellent. Dr. Rosenberg, let me ask you a question. It really hit a point with the scoliosis fact of nearly 100 percent rate in children under the age of 12 will present with scoliosis. So one of my questions is, is there any early interventions or care management techniques that we should be aware of prior to any kind of fusion or rod therapy? Good question. Good question. I thought you were going a different direction, but that's a good one, too. I think so if we're talking about a surgery in any spinal cord injury, I think step one that you think about is making sure your bowel program is great. So you want to go into that surgery with empty bowels, if at all possible. Empty bowels, if at all possible. And so the postoperative bowel program changes sometimes do show up in any spine surgery. So it's like we think about pooping. That's what we think about. And the place I thought you were going, which is probably worth mentioning, is are there anything that can be done to prevent that scoliosis, to prevent its progression? And the one thing that's been studied a little bit is wearing a TLSO, a turtle shell type brace, that's fairly rigid and that has been shown to slow progression and not slow it very well and maybe not even prevent surgery. It's not the best evidence out there. But what I actually get, something that's worth probably discussing and noting with parents is that we've got some kids that have their wheelchair position. Maybe they lean one direction or the other, or they spend a lot of time reaching just to their right or they slouch a little bit. And you've got parents spending 10, 16 hours a day correcting their kid's position. We don't have a lot of good evidence to say that position correction and position changes and wheelchair symmetry impact that scoliosis as much as it's a growth based thing. So sometimes giving parents permission to allow their kids to sit in their most comfortable and functional position is really empowering for them. Very great points, thank you. And then just to touch on the DVT prophylaxis, you talked about Noxaparin. Is there any kind of SED use that we would continue to do as well in elevation of the legs maybe? Yeah, good question. The sequential compression devices are really great in acute care and pretty cumbersome, I think, in life after acute care as we have inpatient rehab as a simulation or a goal of a simulation of home life. And specifically having cables attaching to somebody's bed is oftentimes the opposite of what we're looking for, just mechanistically. And so they become less practical as somebody leaves acute care. But in the acute care setting, certainly sequential compression devices are a strong consideration. And would you be encouraged like family to do passive range of motion on those lower extremities at all or? Yeah, either way, we'll be doing it. Yeah. Does it have a direct impact on DVTs? I don't know the answer to that, but there's 20 other reasons to do passive range. So we'll do it either way. Awesome. Thank you so much, sir. Tara, I have a question for you. Some of your discussion, especially early on, was about prevention, the leading cause of death in spinal cord population from pneumonia and atelectasis. So aggressive pulmonary toileting, is there a certain guidance for the frequency of that pulmonary toileting? I would have to check with our pulmonologists who are in our ICU exactly if they do like on a set time frame, if that's what you're asking, every four hours or every six hours. Usually if they're in our ICU, it is every four hours that they're performing some sort of suctioning. But it is really based on how the patient is progressing and how they're weaning from the ventilator. Excellent. And then elevating the head of the bed, is that going to be kind of the standard 30 degree elevation or are we going to try to get them up a little bit higher than that? And we try to get them up as high as we can, obviously with the shifting the weight so that they're not having too much pressure on one area or the other. But yes, if they can tolerate sitting upright, it would only advance them when they're going to continue to rehab. Excellent. All right. Let me take a look at the chat, see if there's any questions here. I jumped in. As you're looking, I've got a question. I got a question for you, Tara, because it sounds like you've worked in pretty much every setting, right? Every concept might happen. Is there like a conserved thing that you've noticed in terms of caregivers and their approach that like, you know, what's your what's your soapbox topic that you've caught that's lived through all those different phases of care and things like if you could make a difference, you're one liner for the things that things may be outside of our textbook. Is there something that you really like to jump on the soapbox about? I think it's probably more of like the psychological aspects of it is people kind of really don't think about the impact that it has on the caregiver who also usually is the wife or the parent. You know, the parent is a little different because they're always going to be the caregiver for their child, no matter as you know, if they're toddlers or adults. But the the psychological aspects of it, everybody's very focused on the patient and then it continues throughout. And then I see that when they come to home health is everything is revolved around that patient at home. And then when they go to outpatient, usually a family member sits in the lobby. So I think engaging and kind of really and I see it when I do admissions is saying, like, OK, we know how he's doing. How are you doing? Like, what can I what can I answer for you? And I think that as providers, we overlook we're so concentrated on the patient that we're not necessarily looking at the bigger picture of everybody that else is involved in there, too. Bridget, yes. Great. Right, so I'm going to give the chat box a few more moments. I want to thank you all again for this wonderful presentation. We went we went the gamut, we went the 90 minutes. So I appreciate all the time, insight and best practices that were shared for today.

rehabilitation

children

spinal cord injuries

complications

caregiver involvement

prevention

management

pneumonia

bowel and bladder management

pain

individualized care

multidisciplinary approach