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INTRODUCTION: Postprandial hypotension is a type of autonomic dysfunction where there is a decrease in systolic blood pressure of >20 mm HG within 2 h after eating thought to be due to poor cardiovascular compensation for splanchnic blood pooling that occurs with meals. This form of autonomic dysfunction is underdiagnosed in patients with spinal cord injury, likely in part because it can be asymptomatic. CASE PRESENTATION: 26-year-old with complete cervical spinal cord injury (SCI) presented with neck pain described as severe 10/10 pain, which felt like "a rope around his neck." Pain came on during and after meals and was associated with a feeling of pressure behind his eyes, white spots in his vision along with feeling as if he was going to pass out. The caregiver noted a systolic blood pressure drop by about 30-40 points with meals and lost weight due to avoiding eating. A diagnosis of post-prandial hypotension (PPH) was made and Acarbose was started at a low dose 25 mg three times per day with meals. During follow up, the patient reported complete resolution of drops of blood pressure, neck pain, and all associated symptoms. The patient was able to eat comfortably and gained weight. DISCUSSION: There are few case reports on PPH in SCI and none looking at acarbose on a young, nondiabetic person with SCI. Clinicians should be aware that PPH can occur in young otherwise healthy people with SCI. Further research is needed on PPH, including the use of acarbose, in the SCI population.

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BACKGROUND: OnabotulinumtoxinA is commonly used to relieve spasticity in children with neurologic disorders. Ethanol neurolysis may be used to target more muscles but is less well studied, especially in pediatrics. OBJECTIVE: To determine the safety and effectiveness of ethanol neurolysis with onabotulinumtoxinA injections compared to only onabotulinumtoxinA injections for the treatment of spasticity in children with cerebral palsy. DESIGN: Prospective cohort study including patients with cerebral palsy receiving onabotulinumtoxinA and/or ethanol neurolysis from June 2020 to June 2021. SETTING: Outpatient physiatry clinic. PATIENTS: A total of 167 children with cerebral palsy not undergoing other treatments during injection period. INTERVENTIONS: Injection with either onabotulinumtoxinA only (112 children) or a combination of ethanol and onabotulinumtoxinA injections (55 children) using both ultrasound guidance and electrical stimulation. MAIN OUTCOME MEASURES: A post-procedure evaluation at 2 weeks after injection documented any adverse effects experienced by the child and perceived magnitude of improvement using an ordinal scale from 1 to 5. Multiple linear regression was used to identify and control for covariates including Gross Motor Function Classification System, gender, age, weight, ethnicity, race, and dosage. RESULTS: Only weight was identified as a confounding factor. When controlled for weight, combined onabotulinumtoxinA and ethanol injections had a greater magnitude of improvement (3.78/5) compared with onabotulinumtoxinA injections alone (3.44/5), a difference of 0.34 points on the rating scale (95% confidence interval: 0.01-0.69; p = .045). However, the difference was not clinically significant. One patient in the onabotulinumtoxinA-only group and two patients in the combined onabotulinumtoxinA and ethanol group reported mild, self-limiting adverse effects. CONCLUSION: Ethanol neurolysis under ultrasound and electrical stimulation guidance may be a safe and effective treatment for children with cerebral palsy that allows more spastic muscles to be treated than onabotulinumtoxinA alone.

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Cerebral palsy (CP) is a group of non-progressive disorders of motor function in children resulting from an injury to an immature brain. In addition to abnormal limb and trunk movement, individuals with CP can experience involuntary muscle contractions of the lower facial muscle groups, causing oromandibular dystonia (OMD). Contraction of the lateral pterygoids and submandibular muscles depresses the mandible. OMD involving the lateral pterygoids can therefore lead to involuntary jaw opening posture, affecting the ability to feed and speak effectively. We present a case series of five patients with CP and OMD that received novel ultrasound-guided onabotulinumtoxinA to the lateral pterygoid muscles. Our goal was to determine if chemodenervation would improve the mouth-closing ability, thus in turn improving the ability to swallow, chew, manage secretions, and communicate. We describe this unique injection method and report a subjective improvement in eating abilities and communication, in addition to a positive upward trend in most patients' weights, with no significant adverse side effects.

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OBJECTIVE: To examine the relationship between an estimate of sleep-wake regulation derived from actigraphy and determine whether it would be sensitive to neurocognitive dysfunction associated with acquired brain injury (ABI) in a pediatric rehabilitation sample. DESIGN: Cross-sectional design. SETTING: Inpatient pediatric rehabilitation facility. PARTICIPANTS: A sample (N=43) of 31 males (72.1%) and 12 females (27.9%) admitted to a pediatric rehabilitation hospital wore an actigraph (wrist accelerometer) for 1 week. Participant ages ranged from 8 to 17 years (mean, 13.1y; SD, 2.7y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Raw actigraphy activity counts in 1-minute epochs were used to derive a rest-activity ratio over each 24-hour period; a 5-day average value was calculated for Monday through Friday. Brain injury status was derived through medical record review, resulting in the formation of 3 groups: traumatic brain injury (n=14), nontraumatic brain injury (n=16), and a non-ABI control group (n=13). Functional status was measured using FIM for children (WeeFIM) Cognitive and Motor scores extracted from the medical records. RESULTS: Unadjusted models showed a significant main group effect for brain injury status (P=.012). Compared with controls, the rest-activity ratio was significantly lower in both the traumatic brain injury (P=.005), and nontraumatic brain injury (P=.023) groups. However, the main group effect was no longer significant in an adjusted model controlling for WeeFIM Cognitive and WeeFIM Motor scores at admission. In the context of the adjusted model, there was a significant relationship between the rest-activity ratio and WeeFIM Cognitive scores at admission. CONCLUSIONS: Individuals with lower functional status at admission, especially in the cognitive domain, had lower rest-activity ratios, suggesting poorer sleep-wake regulation. Similar to findings in adults with ABI, this ratio may have utility in tracking sleep-wake regulation in the pediatric rehabilitation setting. Future studies should investigate sensitivity to change over the course of recovery and responsiveness to clinical interventions to improve sleep.

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INTRODUCTION: Visual biofeedback of lower extremity kinematics has the potential to enhance retraining of pathological gait patterns. We describe a system that uses wearable inertial measurement units to provide kinematic feedback on error measures generated during periods of gait in which the knee is predominantly extended ('extension period') and flexed ('flexion period'). METHODS: We describe the principles of operation of the system, a validation study on the inertial measurement unit derived knee flexion angle on which the system is based, and a feasibility study to assess the ability of a child with cerebral palsy to modify a gait deviation (decreased swing phase knee flexion) in response to the feedback. RESULTS: The validation study demonstrated strong convergent validity with an independent measurement of knee flexion angle. The gait pattern observed during training with the system exhibited increased flexion in the flexion period with maintenance of appropriate extension in the extension period. CONCLUSIONS: Inertial measurement units can provide robust feedback during gait training. A child with cerebral palsy was able to interpret the novel two phase visual feedback and respond with rapid gait adaptation in a single training session. With further development, the system has the potential to support clinical retraining of deviated gait patterns.

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AIM: We hypothesized that repeat onabotulinumtoxinA (BTX-A) injections to salivary glands would have a cumulative effect on drooling, leading to prolonged efficacy duration. METHODS: We retrospectively reviewed medical records and conducted a telephone survey of individuals treated with BTX-A to the salivary glands to investigate ongoing efficacy or adverse effects. Outcome measures were duration of decrease in drooling and adverse events. The main independent variable was the number of injections. We identified 52 consecutive individuals (26 females) with cerebral palsy with an average age of 9 yrs, 3 mos ± 5 yrs 2 mos, who had received BTX-A for sialorrhea. RESULTS: Linear regression analysis showed that each additional injection resulted in the duration of efficacy being 0.68 mos longer (P < 0.001, R2 = 0.47). Age, sex, Gross Motor Function Classification System level, presence of tube feeding, presence of tracheostomy, gastroesophageal reflex, seizures, and concurrent intramuscular injections seizures were not significant contributors to the association between injection number and efficacy duration (F (6, 45) = 1.01, P = 0.431). INTERPRETATION: There may be a cumulative effect of BTX-A injections to the salivary glands, resulting in longer periods of efficacy with consecutive injection.

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OBJECTIVE: To evaluate the safety of combining salivary gland onabotulinumtoxinA (BTX-A) injections for sialorrhea with intramuscular BTX-A injections for spasticity in the same procedure. DESIGN: A retrospective cohort study in a tertiary hospital center. Patients selected were younger than 20 years, diagnosed with cerebral palsy, and received their first salivary gland BTX-A injection between March 2011 and July 2015. Chart review and telephone interviews were performed. The primary outcome measure was the rate of adverse events after combined BTX-A injections into salivary glands and muscles. The secondary outcome measure was the efficacy of injections, as reported by patients. RESULTS: Twenty-five of the 52 selected patients received salivary gland BTX-A injections only, and 27 received concurrent salivary gland and multi-level intramuscular chemodenervation with BTX-A with or without alcohol. The rate of adverse events was < 10% in both groups; 4% in "Salivary Only Group" and 7% in the "Salivary + Multilevel Intramuscular Chemodenervation with BTX-A group (with or without alcohol)". Both approaches were equally effective in meeting their goals of salivary injections (> 50% improvement for at least two months). In the "salivary only" and in the "salivary + multi-level intramuscular" group, 76 and 85% of the patients reached their goals respectively. CONCLUSIONS: Combining BTX-A injections for sialorrhea with multilevel intramuscular BTX-A injections (with or without alcohol) appears to be safe and effective and allows treatment of patients for both conditions simultaneously.

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OBJECTIVE: The aim of the study was to investigate the safety and efficacy of onabotulinum toxin A injection to the salivary glands under ultrasound guidance for the treatment of sialorrhea in patients with spinal muscular atrophy type I. DESIGN: Prospective case series with four patients with spinal muscular atrophy type I who received onabotulinum toxin A injection to parotid and submandibular glands for sialorrhea as part of clinical care. All four patients received validated surveys for measuring drooling, including objective measures of number of bib changes, and number of mouth wipes before injection and 4-6 wks after injection. Research was limited to survey completion. Scales included the Drooling Severity and Frequency Scale and the Drooling Impact Scale as well as a new scale used in our clinic, the Posterior Drooling Scales looking at coughing/choking and number of aspiration pneumonias. RESULTS: There were no adverse events. All four patients showed clinically significant improvements. The improvement in drooling using the Drooling Impact Scale was statistically significant (paired t test, t = 3.243, P = 0.048). All patients improved with number of mouth wipes. CONCLUSION: Ultrasound-guided onabotulinum toxin A injections to the salivary glands may be a safe and effective method of decreasing drooling in patients with spinal muscular atrophy type I.

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