This cross-sectional analysis of Pediatric Rehabilitation Medicine (PRM) fellowship program websites in the United States assesses their comprehensiveness based on 43 variables commonly sought by applicants. The study found that 30% of programs had a direct link to the PRM fellowship page, with limited information on criteria such as education resources, research stipend, mentorship opportunities, and fellow wellness. The results underscore the need for improved accessibility, content expansion, and yearly link maintenance. These improvements could enhance the applicant experience, foster informed decisions, and streamline the application process. The findings offer a roadmap for PRM fellowships to better align their online platforms with applicant needs, reflecting the current shift toward virtual interactions in the post-pandemic era.

Peripheral nerve injury can lead to chronic pain, paralysis, and loss of sensation, severely affecting quality of life. Spinal cord stimulation has been used in the clinic to provide pain relief arising from peripheral nerve injuries, however, its ability to restore function after peripheral nerve injury have not been explored. Neuromodulation of the spinal cord through transcutaneous spinal cord stimulation (tSCS), when paired with activity-based training, has shown promising results towards restoring volitional limb control in people with spinal cord injury. We show, for the first time, the effectiveness of targeted tSCS in restoring strength (407% increase from 1.79 ± 1.24 N to up to 7.3 ± 0.93 N) and significantly increasing hand dexterity in an individual with paralysis due to a peripheral nerve injury (PNI). Furthermore, this is the first study to document a persisting 3-point improvement during clinical assessment of tactile sensation in peripheral injury after receiving 6 weeks of tSCS. Lastly, the motor and sensory gains persisted for several months after stimulation was received, suggesting tSCS may lead to long-lasting benefits, even in PNI. Non-invasive spinal cord stimulation shows tremendous promise as a safe and effective therapeutic approach with broad applications in functional recovery after debilitating injuries.

Background: Emergency department (ED) visits for altered mental status (AMS) in children are common. Neuroimaging is often performed to ascertain etiology, but its utility has not been well studied. Our objective is to describe the yield of neuroimaging studies in children who present to an ED with AMS. Methods: We performed a retrospective chart review of children 0-18 years of age, presenting to our PED between 2018 and 2021 with AMS. We abstracted patient demographics, physical examination, neuroimaging and EEG results, and final diagnosis. Neuroimaging and EEG studies were classified as normal or abnormal. Abnormal studies were categorized as clinically important and contributory: abnormalities that were clinically important and contributed to the etiology, clinically important but noncontributory: abnormalities that were clinically significant but did not explain the etiology, and incidental: abnormalities that were not clinically significant. Results: We analyzed 371 patients. The most common etiology of AMS was toxicologic (188, 51%) with neurologic causes (n = 50, 13.5%) accounting for a minority. Neuroimaging was performed in one-half (169, 45.5%) and abnormalities were noted in 44 (26%) studies. Abnormalities were clinically important and contributed to the etiologic diagnosis of AMS in 15/169 (8.9%), clinically important and noncontributory in 18/169 (10.7%), and incidental in 11/169 (6.5%). EEG was performed in 65 patients (17.5%), of which 17 (26%) were abnormal with only one being clinically important and contributory. Conclusions: Though neuroimaging was performed in approximately one half of the cohort, it was contributory in a minority. Similarly, diagnostic utility of EEG in children with AMS was low.

Acute flaccid myelitis (AFM) occurs rarely in children and adolescents when damage to spinal motor neurons rapidly causes flaccid paralysis of limb, trunk, and neck muscles and potentially respiratory failure. When neck muscles are weakened or paralyzed, a child loses head control, severely compromising engagement with their environment. Compensation for lack of head control is achieved with external support devices attached to a wheelchair, but there is no indication in the AFM literature of therapeutic efforts to restore head control. In this case series, we explore the possibility of the recovery of head control when children with AFM received activity-based restorative therapies (ABRTs) guided by principles targeting motor control. Three children, two male and one female, aged 6, 9, and 7, with a history of AFM-onset at 5, 7, and 4 years respectively, enrolled in an activity-based restorative therapies outpatient program targeting activation of the neuromuscular system below the lesion. Each of them lacked head control, was either ventilator-dependent or had a tracheostomy, and was a power wheelchair user via hand/foot control. Activity-based restorative therapies were provided 5 days/week: 1.5 h of activity-based locomotor training and 1.5 h of activity-based neuromuscular electrical stimulation. An approach to addressing head/neck control developed iteratively across disciplines, from complete compensation with passive external head support to emerging head control during diverse tasks, e.g., sitting, reaching, driving a power chair, sit-to-stand, standing, stepping on a treadmill, and walking. Key principles identified and employed were (a) passive facilitation, (b) external head support, (c) posterior head support, (d) graded manual facilitation, and (e) independent head control. The recovery of head control in children with paralysis due to AFM may be accelerated when executing a step-wise progression to effectively target and challenge head control in parallel with activity-based restorative therapies. In treating three children with a chronic lack of head control, a therapeutic strategy was iteratively developed guided by scientific principles, e.g., segmental assessment of control, to promote recovery of head control. While this strategy is encouraging, gaps in sensitive and responsive measurement instruments and treatment technologies persist in guiding assistance, challenging, and promoting independent head control.

The lack of sensory feedback from the foot contributes to balance impairments and falls in individuals with a lower-limb amputation. Ongoing research focuses on developing somatosensory neuroprostheses to restore sensation to the missing limb via electrical stimulation; however, participants often report that the sensations produced by the stimulation are unintuitive. The impact of sensory intuitiveness on prosthetic function has not yet been established, in part due to the lack of a reliable metric of intuitiveness. Previous work has proposed a speeded cross-modal congruency task as a means to quantify intuitiveness for upper-limb somatosensory neuroprostheses. Participants verbally indicate the location of evoked sensations while ignoring a visual distractor at the same or another location (congruent or incongruent trials, respectively). The magnitude of slowing of response times for incongruent trials, called the cross-modal congruence effect (CCE), has been used to measure intuitiveness, under the assumption that more intuitive sensations will be more intrusive. This study modified the task to evaluate the intuitiveness of two types of evoked sensations (electrotactile or pneumotactile) in the knee and foot. Fifteen able-bodied individuals completed the modified task. The CCE was higher for pneumotactile stimulation compared to electrotactile stimulation at the knee, but not at the foot. The location dependence of the CCE in the lower extremity suggests that it is not a good proxy for sensory intuitiveness in the lower-limb and thus should not be used for assessing lower-limb somatosensory neuroprostheses.

Incomplete spinal cord injuries (ISCI) in pediatrics and adults can lead to asymmetric motor impairments exhibiting as asymmetries of posture and gait. Recently, rehabilitation guidelines for adults with neurologic injuries have focused on gaining a functional gait pattern as measured by speed and distance, even if asymmetry deficits persist. Activity-based restorative therapies (ABRT) take advantage of activity-dependent neuroplasticity to change an individual's neuromuscular capacity. This is a report of an ambulatory child with chronic ISCI presenting with significant postural and gait asymmetries who enrolled in an ABRT program. Across 79 ABRT sessions, the child gained symmetry during sitting, standing, and walking. Even though this child was a functional ambulator at enrollment, targeting symmetry of movements via improved neuromuscular capacity further enhanced her achievement of kinematically appropriate function for participation in daily activities.

Introduction: Lumbosacral spinal cord neuromodulation has shown the ability to restore voluntary control and stepping in individuals with chronic spinal cord injury. Methods: We combined cervical transcutaneous and lumbar epidural stimulation to explore the brain-spinal connectomes and their influence in spinal excitability and interlimb coupling. Four individuals with a prior implanted lumbosacral spinal cord epidural stimulator participated in the study. We assessed lower extremity muscle activity and kinematics during intentional stepping in both non-weight bearing and weight-bearing environments. Results: Our results showed an inhibition of motor evoked potentials generated by spinal cord epidural stimulation when cervical transcutaneous stimulation is applied. In contrast, when intentional stepping is performed in a non-weight bearing setting, range of motion, motor output amplitude, and coordination are improved when cervical transcutaneous and lumbar epidural stimulations are combined. Similarly, with both stimulations applied, coordination is improved and motor output variability is decreased when intentional stepping is performed on a treadmill with body weight support. Discussion: Combined transcutaneous cervical and epidural lumbar stimulation demonstrated an improvement of voluntary control of stepping in individuals with chronic motor complete paralysis. The immediate functional improvement promoted by the combination of cervical and lumbar stimulation adds to the body of evidence for increasing spinal excitability and improvement of function that is possible in individuals with chronic paralysis.

The immature central nervous system is recognized as having substantial neuroplastic capacity. In this study, we explored the hypothesis that rehabilitation can exploit that potential and elicit reciprocal walking in nonambulatory children with chronic, severe (i.e., lower extremity motor score < 10/50) spinal cord injuries (SCIs). Seven male subjects (3-12 years of age) who were at least 1-year post-SCI and incapable of discrete leg movements believed to be required for walking, enrolled in activity-based locomotor training (ABLT; clinicaltrials.gov NCT00488280). Six children completed the study. Following a minimum of 49 sessions of ABLT, three of the six children achieved walking with reverse rolling walkers. Stepping development, however, was not accompanied by improvement in discrete leg movements as underscored by the persistence of synergistic movements and little change in lower extremity motor scores. Interestingly, acoustic startle responses exhibited by the three responding children suggested preserved reticulospinal inputs to circuitry below the level of injury capable of mediating leg movements. On the other hand, no indication of corticospinal integrity was obtained with transcranial magnetic stimulation evoked responses in the same individuals. These findings suggest some children who are not predicted to improve motor and locomotor function may have a reserve of adaptive plasticity that can emerge in response to rehabilitative strategies such as ABLT. Further studies are warranted to determine whether a critical need exists to re-examine rehabilitation approaches for pediatric SCI with poor prognosis for any ambulatory recovery.