Pharmacologic Treatment and Early Rehabilitation Outcomes in Pediatric Patients With Anti-NMDA Receptor Encephalitis.

OBJECTIVES: To describe the immunotherapy and pharmacologic treatments administered to pediatric patients with N-methyl-D-aspartate receptor encephalitis (NMDARE) during inpatient rehabilitation as well as to examine clinical and demographic variables associated with early functional outcomes. DESIGN: Retrospective chart review and post hoc analysis. SETTING: Pediatric inpatient rehabilitation unit. PARTICIPANTS: Pediatric patients (N=26; mean age, 10.79±5.17y) admitted to an inpatient rehabilitation unit with a confirmed diagnosis of NMDARE. INTERVENTIONS: Inpatient rehabilitation; pharmacologic treatments. MAIN OUTCOME MEASURE: FIM for Children (WeeFIM) Developmental Functional Quotient (DFQ). RESULTS: All patients received first-line immunotherapies to treat NMDARE, and 69% also received second-line immunotherapies. Patients were prescribed an average of 8 medications for symptom management (range, 3-15 per patient), most often for the treatment of agitation (100%), psychiatric symptoms (92%), and seizures (65%). Sixty-five percent of patients demonstrated an improvement in Total WeeFIM DFQ over the course of inpatient rehabilitation, with 35% demonstrating limited to no change in Total WeeFIM DFQ ("unfavorable early outcome"). Those with unfavorable early outcome were significantly younger than those showing more favorable outcome. Pharmacologic treatment for seizures, movement disorders, and decreased arousal or level of consciousness were each associated with unfavorable early outcome independent of age differences. CONCLUSION: Findings highlight the symptomatic heterogeneity and polypharmacy involved in the care and treatment of patients with NMDARE, with patients receiving a variety of immunotherapies and medications for symptom management. The presence of (and treatment for) seizures, movement disorders, and deteriorated neurologic status may each be associated with poor early outcomes in this population. Further investigation is needed to better classify presentations and treatments for this disease and to determine how differences are associated with long-term outcomes.

Jump Performance and Its Relationship with Lower Body Joint Kinetics and Kinematics in Children with Cerebral Palsy.

PURPOSE: The aim was to quantify jump performance in children with cerebral palsy (CP) and determine if the expected deficit is related to their lower body joint kinetics and kinematics. METHODS: Twenty-four ambulatory ( n = 17 level I and 7 level II in the Gross Motor Function Classification System) children with spastic CP ( n = 13 unilateral and 11 bilateral) and 24 age-, sex-, and race-matched typically developing controls were studied. Jump height and peak power and range of motion at the hip, knee, and ankle of the more affected limb in children with CP and the nondominant limb in controls were assessed during a countermovement jump using three-dimensional motion capture and a force platform. RESULTS: Compared with controls, children with CP had lower jump height (33%, Cohen's d ( d ) = 1.217), peak power at the knee (39%, d = 1.013) and ankle (46%, d = 1.687), and range of motion at the hip (32%, d = 1.180), knee (39%, d = 2.067), and ankle (46%, d = 3.195; all P < 0.001). Jump height was positively related to hip, knee, and ankle power and range of motion in children with CP ( rs range = 0.474-0.613, P < 0.05), and hip and ankle power and knee and ankle range of motion in controls ( rs range = 0.458-0.630, P < 0.05). The group difference in jump height was no longer detected when ankle joint power, ankle range of motion, or knee range of motion was statistically controlled ( P > 0.15). CONCLUSIONS: Jump performance is compromised in children with CP and is associated with low power generation and range of motion in the lower limb, especially at the ankle.

Evaluation, Treatment, and Outcomes of Viral and Autoimmune Encephalitis in Children.

Viral encephalitis and autoimmune encephalitis are currently the most common causes of encephalitis. Determining the causative agent is helpful in initiating medical treatment that may help reduce long-term sequelae. Cerebrospinal fluid, neuroimaging, serologic, and electroencephalogram in combination with clinical manifestations play a role in determining the cause of the encephalitis. Although motor dysfunction tends to improve, there is a significant risk of long-term neurologic and cognitive sequelae. These persistent deficits that occur in childhood indicate the importance for ongoing rehabilitative services to maximize functional skills, improve cognitive deficits, and assist with community integration.

Early mobilization in a pediatric intensive care unit and WeeFIM scores at rehabilitation: A retrospective study.

PURPOSE: The purpose of this study was to examine the relationship between early mobility (EM) of pediatric patients mechanically ventilated and functional outcomes in rehabilitation using WeeFIM scores, as well as hospital length of stay (LOS), ICU LOS, and rehabilitation LOS. METHODS: A retrospective chart review of 189 patients was completed to compare those who received EM interventions to those who did not in the ICU. Data extracted from the years 2015-2019 included: all patients who were between zero and 21 years, were mechanically ventilated via endotracheal tube (ETT) for > 48 hours, and then transferred to the comprehensive inpatient rehabilitation unit (IRU). RESULTS: For respiratory patients, the EM group had higher WeeFIM scores in all categories at admission to IRU compared to the comparison group. Neurosurgery patients had higher cognition and total WeeFIM scores in the EM group at admission to IRU. All diagnoses demonstrated shorter hospital, ICU, and IRU LOS for the comparison group versus the EM group. CONCLUSION: EM of mechanically ventilated pediatric patients with a primary respiratory diagnosis demonstrated improved function at admission to IRU compared to those who did not participate in EM. Prospective research needs to be done to examine this relationship further.

Core components of a rehabilitation program in pediatric cardiac disease.

There is increasing effort in both the inpatient and outpatient setting to improve care, function, and quality of life for children with congenital heart disease, and to decrease complications. As the mortality rates of surgical procedures for congenital heart disease decrease, improvement in perioperative morbidity and quality of life have become key metrics of quality of care. Quality of life and function in patients with congenital heart disease can be affected by multiple factors: the underlying heart condition, cardiac surgery, complications, and medical treatment. Some of the functional areas affected are motor abilities, exercise capacity, feeding, speech, cognition, and psychosocial adjustment. Rehabilitation interventions aim to enhance and restore functional ability and quality of life for those with physical impairments or disabilities. Interventions such as exercise training have been extensively evaluated in adults with acquired heart disease, and rehabilitation interventions for pediatric patients with congenital heart disease have similar potential to improve perioperative morbidity and quality of life. However, literature regarding the pediatric population is limited. We have gathered a multidisciplinary team of experts from major institutions to create evidence- and practice-based guidelines for pediatric cardiac rehabilitation programs in both inpatient and outpatient settings. To improve the quality of life of pediatric patients with congenital heart disease, we propose the use of individualized multidisciplinary rehabilitation programs that include: medical management; neuropsychology; nursing care; rehabilitation equipment; physical, occupational, speech, and feeding therapies; and exercise training.

A consensus statement on the use of botulinum toxin in pediatric patients.

Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.

A narrative review of pharmacologic approaches to symptom management of pediatric patients diagnosed with anti-NMDA receptor encephalitis.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis (ANMDARE) is one of the most common autoimmune encephalitis in the pediatric population. Patients with ANMDARE initially present with a prodrome of neuropsychiatric symptoms followed by progressively worsening seizures, agitation, and movement disorders. Complications can include problems such as aggression, insomnia, catatonia, and autonomic instability. Due to the complexity of this disease process, symptom management can be complex and may lead to significant polypharmacy. The goal of this review is to educate clinicians about the challenges of managing this disorder and providing guidance in symptom management.

A pragmatic approach to Botulinum Toxin safety.

Botulinum Toxin (BoNT) is widely used to treat hypertonia in pediatric patients. Although serious adverse events (AEs) occur infrequently, they can lead to significant patient morbidity and mortality. This paper will discuss potential safety risks that may affect outcomes, medical comorbidities, medication dosing, targeting techniques, and muscle morphology. It is the responsibility of the physician to discuss risks and benefits regarding the use of BoNT and mitigate risks of AEs while maximizing the effectiveness of the medication.

Nerve and Tendon Transfers After Spinal Cord Injuries in the Pediatric Population: Clinical Decision Making and Rehabilitation Strategies to Optimize Function.

With improvements in medical care, pediatric patients with spinal cord injuries with tetraplegia are living into adulthood. The goal of rehabilitation following loss of upper extremity function caused by tetraplegia is to maximize function and independence. Physiatrists must be aware of appropriate timing of referral for upper extremity surgery because it can have significant ramifications on the outcome. This article discusses the 2 most commonly used surgical strategies to restore upper extremity function: upper extremity tendon transfer and nerve grafting/transfer. Patient selection, physical examination, electrodiagnostic evaluation, and optimization of postoperative rehabilitation are important.

Early Functional Outcomes for Pediatric Patients Diagnosed with Anti-N-Methyl-D-Aspartate Receptor Encephalitis during Inpatient Rehabilitation.

OBJECTIVE: The aims of the current study were to characterize the demographic and clinical presentation of pediatric patients diagnosed with anti-N-methyl-D-aspartate receptor encephalitis who require inpatient rehabilitation, to examine early functional outcomes, and to investigate predictors of early recovery. DESIGN: A retrospective chart review was conducted for 27 pediatric patients diagnosed with anti-N-methyl-D-aspartate receptor encephalitis who received intensive inpatient neurorehabilitation. RESULTS: On average, patients were 10.6 yrs of age (range, 2-18 yrs) at the time of symptom onset. Average time to treatment from symptom onset was 27.2 days (range, 5-91 days). Patients displayed significant improvements between admission and discharge Functional Independence Measure for Children (WeeFIM) Developmental Functional Quotient (DFQ) scores across patients (P < 0.01). Mean Functional Independence Measure for Children Total Developmental Functional Quotient score at admission was 28.6 (range, 15.0-62.6) and at discharge was 54.3 (range, 14.2-91.9). Younger age at onset, seizures, and number of treatments received were associated with worse functional outcomes at discharge. Time to initiate treatment was not found to be associated with early functional outcomes. CONCLUSION: Pediatric patients diagnosed with anti-N-methyl-D-aspartate receptor encephalitis displayed significant functional gains during inpatient rehabilitation, despite persistent functional deficits at discharge, suggesting the need for ongoing monitoring and intervention. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to (1) Recognize the clinical presentation of anti-N-methyl-D-aspartate receptor encephalitis in pediatric patients, (2) Appreciate the role of rehabilitation in the care of the pediatric patient with anti-N-methyl-D-aspartate receptor encephalitis, and (3) Identify demographic and clinical variables that predict poor functional outcomes after rehabilitation in pediatric patients with anti-N-methyl-D-aspartate receptor encephalitis. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Amantadine-Induced Corneal Edema in a Pediatric Neuro-Oncology Patient: A Case Report.

Amantadine is commonly prescribed as a neurostimulant in patients with brain injuries. This is a case of a 14-year-old male with a history of brain tumor that developed corneal edema after initiation of amantadine, a rare but documented side effect of this medication. After discontinuation of amantadine, the corneal edema resolved within two months, but endothelial cells density remained low. LEVEL OF EVIDENCE: V.