Functional recovery measures for spinal cord injury: an evidence-based review for clinical practice and research

BACKGROUND/OBJECTIVE

The end goal of clinical care and clinical research involving spinal cord injury (SCI) is to improve the overall ability of persons living with SCI to function on a daily basis. Neurologic recovery does not always translate into functional recovery. Thus, sensitive outcome measures designed to assess functional status relevant to SCI are important to develop.

METHOD

Evaluation of currently available SCI functional outcome measures by a multinational work group.

RESULTS

The 4 measures that fit the prespecified inclusion criteria were the Modified Barthel Index (MBI), the Functional Independence Measure (FIM), the Quadriplegia Index of Function (QIF), and the Spinal Cord Independence Measure (SCIM). The MBI and the QIF were found to have minimal evidence for validity, whereas the FIM and the SCIM were found to be reliable and valid. The MBI has little clinical utility for use in the SCI population. Likewise, the FIM applies mainly when measuring burden of care, which is not necessarily a reflection of functional recovery. The QIF is useful for measuring functional recovery but only in a subpopulation of people with SCI, and substantial validity data are still required. The SCIM is the only functional recovery outcome measure designed specifically for SCI.

CONCLUSIONS

The multinational work group recommends that the latest version of the SCIM (SCIM III) continue to be refined and validated and subsequently implemented worldwide as the primary functional recovery outcome measure for SCI. The QIF may continue to be developed and validated for use as a supplemental tool for the nonambulatory tetraplegic population.

Efficacy of an implanted neuroprosthesis for restoring hand grasp in tetraplegia: a multicenter study

OBJECTIVE

To evaluate an implanted neuroprosthesis that allows tetraplegic users to control grasp and release in 1 hand.

DESIGN

Multicenter cohort trial with at least 3 years of follow-up. Function for each participant was compared before and after implantation, and with and without the neuroprosthesis activated.

SETTING

Tertiary spinal cord injury (SCI) care centers, 8 in the United States, 1 in the United Kingdom, and 1 in Australia.

PARTICIPANTS

Fifty-one tetraplegic adults with C5 or C6 SCIs.

INTERVENTION

An implanted neuroprosthetic system, in which electric stimulation of the grasping muscles of 1 arm are controlled by using contralateral shoulder movements, and concurrent tendon transfer surgery. Assessed participants' ability to grasp, move, and release standardized objects; degree of assistance required to perform activities of daily living (ADLs), device usage; and user satisfaction.

MAIN OUTCOME MEASURES

Pinch force; grasp and release tests; ADL abilities test and ADL assessment test; and user satisfaction survey.

RESULTS

Pinch force was significantly greater with the neuroprosthesis in all available 50 participants, and grasp-release abilities were improved in 49. All tested participants (49/49) were more independent in performing ADLs with the neuroprosthesis than they were without it. Home use of the device for regular function and exercise was reported by over 90% of the participants, and satisfaction with the neuroprosthesis was high.

CONCLUSIONS

The grasping ability provided by the neuroprosthesis is substantial and lasting. The neuroprosthesis is safe, well accepted by users, and offers improved independence for a population without comparable alternatives.

Outcome measures in spinal cord injury: recent assessments and recommendations for future directions

STUDY DESIGN

Review by the spinal cord outcomes partnership endeavor (SCOPE), which is a broad-based international consortium of scientists and clinical researchers representing academic institutions, industry, government agencies, not-for-profit organizations and foundations.

OBJECTIVES

Assessment of current and evolving tools for evaluating human spinal cord injury (SCI) outcomes for both clinical diagnosis and clinical research studies.

METHODS

a framework for the appraisal of evidence of metric properties was used to examine outcome tools or tests for accuracy, sensitivity, reliability and validity for human SCI.

RESULTS

Imaging, neurological, functional, autonomic, sexual health, bladder/bowel, pain and psychosocial tools were evaluated. Several specific tools for human SCI studies have or are being developed to allow the more accurate determination for a clinically meaningful benefit (improvement in functional outcome or quality of life) being achieved as a result of a therapeutic intervention.

CONCLUSION

Significant progress has been made, but further validation studies are required to identify the most appropriate tools for specific targets in a human SCI study or clinical trial.

An innovative technique of vertebral body stapling for the treatment of patients with adolescent idiopathic scoliosis: a feasibility, safety, and utility study

STUDY DESIGN

Retrospective review.

OBJECTIVES

To report the feasibility, safety, and utility of vertebral body stapling without fusion as an alternative treatment for adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

The success rate of brace treatment of adolescent idiopathic scoliosis ranges from 50% to 82%. However, poor self-image and brace compliance are issues for the patient. An alternative method of treatment such as a motion-preserving vertebral body stapling to provide curve stability would be desirable.

METHODS

We retrospectively reviewed 21 patients (27 curves) with adolescent idiopathic scoliosis treated with vertebral body stapling. Patients were immature as defined by Risser sign <or=2.

RESULTS

The concept of vertebral body stapling of the convex side of a patient with adolescent idiopathic scoliosis is feasible. The procedure was safe, with no major complications and three minor complications. One patient had an intraoperative segmental vein bleed resulting in an increased estimated blood loss of 1500 cc as compared to the average estimated blood loss of 247 cc for all patients. One patient had a chylothorax and one pancreatitis. No patient has had a staple dislodge or move during the follow-up period (mean 11 months, range 3-36 months), and no adverse effects specifically from the staples have been identified. Utility (defined as curve stability) was evaluated in 10 patients with stapling with greater than 1-year follow-up (mean 22.6 months) and preoperative curve <50 degrees. Progression of >or=6 degrees or beyond 50 degrees was considered a failure of treatment. Of these 10 patients, 6 (60%) remained stable or improved and 4 (40%) progressed. One of 10 (10%) in the stapling group had progressed beyond 50 degrees and went on to fusion. Six patients required stapling of a second curve, three as part of the primary surgery, and three as a second stage, because a second untreated curve progressed. The results need to be considered with caution, as the follow-up is still short.

CONCLUSIONS

The data demonstrate that vertebral body stapling for the treatment of scoliosis in the adolescent was feasible and safe in this group of 21 patients. In the short-term, stapling appears to have utility in stabilizing curves of progressive adolescent idiopathic scoliosis.

Vertebral body stapling procedure for the treatment of scoliosis in the growing child

Thirty-nine consecutive patients have had vertebral body stapling of 52 curves (26 patients with one curve stapled and 13 with two). For the group with patients who were 8 years or older with less than 50 degrees preoperative curve and a minimum 1-year followup, coronal curve stability was 87% when defined by progression less than or equal to 10 degrees . Fusion was necessary in two patients. No curves less than 30 degrees at the time of stapling progressed greater than or equal to 10 degrees . Major complications occurred in one patient (2.6%, diaphragmatic hernia) and minor complications occurred in five patients (13%). Further followup of the patient cohort and further research into efficacy and indications are warranted.

The International Standards for Neurological Classification of Spinal Cord Injury: reliability of data when applied to children and youths

STUDY DESIGN

Intra-rater reliability study, cross-sectional design.

OBJECTIVES

To determine reliability of the International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) motor and sensory exam in children.

SETTING

Nonprofit pediatric hospital.

METHODS

In all, 74 subjects had two trials of the motor and sensory exams. Intraclass correlation coefficients (ICC), 95% confidence intervals (CI) were generated for total motor (TM), pin prick (PP) and light touch (LT) scores for the entire sample, four age groups, severity and type of injury. Coefficients >0.90=high reliability; 0.75-0.90=moderate reliability and <0.75=inadequate reliability.

RESULTS

Children <four years (N=7) were unable to participate in the exams. TM ICC, CI=0.888, 0.821-0.93 (N=73); PP ICC, CI=0.975, 0.96-0.98 (N=67) and LT ICC, CI=0.974, 0.974-0.985 (N=68). When age was considered, 4-5 year: TM ICC, CI=0.917, 0.69-0.98 (N=11), PP=0.912, 0.49-0.985 (N=7), LT=0.948, 0.63-0.993 (N=6); for 6-11 year: TM ICC, CI=0.711, 0.226-0.892 (N=18), PP=0.952, 0.867-0.983 (M=17), LT=0.952, 0.867-0.983 (N=17); for 12-15 year: TM ICC, CI=0.893, 0.723-0.959 (N=19), PP=0.982, 0.953-0.993 (N=19), LT=0.982, 0.953-0.993 (N=19); for 16-21 year: TM ICC, CI=0.912, 0.80-0.961 (N=25), PP=0.98, 0.954-0.991 (N=25), LT=0.98, 0.954-0.991 (N=25). ICC for severity and type of injury >0.90 except for TM in complete injuries (0.808).

CONCLUSION

The ISCSCI exams may have poor utility in children under 4 years. While reliability values for the motor and sensory exams met or exceeded recommended values, wide CI suggest poor precision of the motor exam in children under 15 years of age and sensory exams in children under 5 years.

Environmental toxicants may modulate osteoblast differentiation by a mechanism involving the aryl hydrocarbon receptor

The AHR mediates many of the toxicological effects of aromatic hydrocarbons. We show that AHR expression in osteoblasts parallels the induction of early bone-specific genes involved in maturation. The AHR may not only mediate the effects of toxicants, but with an as yet unidentified ligand, be involved in the differentiation pathways of osteoblasts.

INTRODUCTION

Metabolic bone diseases arise as a result of an imbalance in bone cell activities. Recent evidence suggests that environmental toxicants may be contributing factors altering these activities. One candidate molecule implicated in mediating the toxic effects of exogenous compounds is the aryl hydrocarbon receptor (AHR).

MATERIALS AND METHODS

Osteoblasts isolated from neonatal rat calvaria were analyzed for AHR expression by quantitative PCR, Western blot, and immunohistochemistry. In addition, AHR activation was evaluated by electromobility gel shift assay and fluorescence microscopy.

RESULTS

Our findings showed AHR expression in mature osteoblasts in vivo. The pattern of AHR expression peaks after alkaline phosphatase and before induction of osteocalcin. We first show that AHR functions as a transactivating receptor in osteoblasts, as evidenced by its ligand-dependent migration to the nucleus and its association with known dioxin response elements. AHR activation by 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) mediated the induction of cytochrome p450 1A1 and cycloxygenase-2 protein levels. This effect could be inhibited by the potent AHR antagonist, 3'4 methoxynitroflavone. Furthermore, lead treatment of osteoblasts upregulates the expression of AHR mRNA and protein levels, supporting a novel mechanism whereby lead in the skeleton may increase the sensitivity of bone cells to toxicant exposure.

CONCLUSIONS

These data imply that the AHR mediates the effects of aromatic toxicants on bone and that AHR expression is regulated during osteoblast differentiation.

International standards for neurological classification of spinal cord injury: training effect on accurate classification

OBJECTIVE

To evaluate the accuracy and agreement of International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) classification and to determine the effectiveness of formal training for pediatric clinicians.

STUDY POPULATION

Participants (N = 28) in a formal 90-minute classification training session.

OUTCOME MEASURE

Pre/post-training examination of 10 case examples of a variety of neurological classifications.

RESULTS

Regardless of years of experience with the ISCSCI, a statistically significant improvement (P < 0.05) in classification was achieved after formal training. Before training, 27% (539 of 1,960) of the questions were answered incorrectly. After training, the percentage of incorrect classifications decreased to 11% (198 of 1,960) incorrect (P < 0.05). After training, the percentage of incorrect motor level classifications decreased by 23% (42% to 19% incorrect; P< 0.05). Post-training improvements were also demonstrated (P< 0.05) in classifying sensory levels (9% to 3% incorrect), neurological levels (31% to 6% incorrect), and severity of injury (9% to 0% incorrect). After training, reductions in classification errors (P < 0.05) were demonstrated in American Spinal Injury Association (ASIA) Impairment Scale (AIS) A (from 20% to 7%), B (50% to 11%), C (71% to 46%), and D (63% to 16%).

CONCLUSIONS

This study demonstrated the benefits of formal, standardized training for accurate classification of the ISCSCI. Effective training programs must emphasize the guidelines and decision algorithms used to determine motor level and ASIA AIS designations because these remained problematic after training and are often a concern of patients/parents and are primary endpoints in clinical trials for neurological recovery.

Prospective evaluation of biceps to triceps and deltoid to triceps for elbow extension in tetraplegia

PURPOSE

The purpose of this study was to evaluate and compare the deltoid to triceps and biceps to triceps transfers for restoration of elbow extension in young persons with tetraplegia.

METHODS

This was a prospective randomized study. Sixteen arms of 9 subjects between 8 and 20 years of age with cervical-level spinal cord injuries were assigned randomly to undergo either a deltoid to triceps transfer or a biceps to triceps transfer. All arms were followed-up prospectively for at least 2 years after surgery.

RESULTS

Elbow extension was restored in 8 arms via the deltoid and in 8 arms via the biceps transfers. At the 24-month follow-up evaluation 7 of the 8 biceps transfers produced antigravity strength (grade 3 or better); in contrast only one arm with the deltoid transfer was able to extend against gravity. There was a considerable but subclinical loss (no subject appreciated any functional deficit) of elbow flexion torque after both transfers. Three months after surgery the deltoid group showed a 51% loss of elbow flexion torque and the biceps group showed a 52% loss of elbow flexion torque. By 24 months after surgery both groups improved but still showed a loss of flexion torque (deltoid 32%, biceps 47%). After gaining elbow extension the subjects in both groups rated the performance of most activities of daily living (ADL) and all self-selected activities as better, as measured on the Modified University of Minnesota Tendon Transfer Functional Improvement Questionnaire and the Canadian Occupational Performance Measure, respectively. Likewise all subjects were more satisfied with performance of their goals after undergoing elbow extension reconstruction.

CONCLUSIONS

This study showed the benefits of restoring elbow extension in persons with tetraplegia and provided support for the biceps transfer as an alternative to the deltoid to triceps transfer in individuals with good brachialis and supinator strength.

Evaluation of the lower motor neuron integrity of upper extremity muscles in high level spinal cord injury

PURPOSE

To evaluate the lower motor neuron (LMN) integrity of upper extremity muscles of persons with high tetraplegia (C1-C4) in order to determine muscles available for stimulation.

METHODS

Fourteen subjects (23 arms) were evaluated for LMN integrity. Muscles that elicited a functional response (grade 3 or better) to surface electrical stimulation were considered to have intact LMN and good candidates for FES. Strength-duration (S-D) curves were generated on muscles that showed weak (less than grade 3) or no response to surface stimulation. Muscles were considered denervated if S-D curves were discontinuous or depicted steep, increasing amplitude for pulse durations greater than 1 m.

RESULTS

Muscles for grasp and release had intact LMN in 19 of 23 (83%) arms. The wrist extensors and flexors and pronator were excitable in 17 (74%), 20 (87%) and 19 (83%) arms, respectively. The supinator demonstrated LMN lesion in 80% of the arms. Over 90% of the biceps muscles were unresponsive to electrical stimulation and 85% and 87% of the deltoid and supraspinatus muscles, respectively, were not electrically excitable. The latissimus dorsi and triceps muscles were typically innervated (78% and 91%, respectively) and slightly more than half (52%) of the pectoralis major muscles were excitable.

CONCLUSION

These data suggest that application of FES in high tetraplegia for hand and arm function would require augmentation because of the inability to stimulate the elbow flexors, deltoid and rotator cuff muscles. These data also show that several paralyzed proximal muscles with intact LMN that have been historically transferred to address shoulder paralysis in other patient populations are available for transfer and stimulation in the population with high level spinal injuries.

Implantable FES system for upright mobility and bladder and bowel function for individuals with spinal cord injury

STUDY DESIGN

Postintervention.

OBJECTIVES

To determine the effectiveness of the Praxis multifunctional implantable functional electrical stimulation (FES) system (Neopraxis Pty. Ltd, Lane Cove, NSW, Australia) to provide standing and stepping ability and bladder and bowel management for individuals with motor complete thoracic level spinal cord injuries (SCI).

SETTING

Pediatric orthopedic hospital specializing in SCI.

SUBJECTS

Three males, ages 17 and 21 years, with motor-complete thoracic level SCI and intact lower motor neurons to the muscles targeted for stimulation.

METHODS

Each subject was successfully implanted with the Praxis FES system. All three subjects received electrodes for upright mobility and the first two subjects received additional electrodes for stimulated bladder and bowel management. Following training, subjects were evaluated in their ability to use FES for nine mobility activities. Acute and chronic experiments of the effect of stimulation on bowel and bladder function were also performed.

RESULTS

All three subjects could independently stand up from the wheelchair and could walk at least 6 m using a swing through gait pattern. Two subjects were able to independently perform swing through gait for 6 min and one subject was able to independently ascend and descend stairs. Suppression of reflex bladder contractions by neuromodulation (subject 1) and stimulated contractions of the rectum (subject 2) were observed in acute experiments. When stimulation was applied over the course of several weeks, a positive effect on bowel function was measured. Stimulated bladder contractions were not achieved.

CONCLUSION

The feasibility of using the Praxis FES system for upright mobility and aiding aspects of bladder and bowel function was demonstrated with three subjects with thoracic level SCI.

Diffusion tensor imaging of the pediatric spinal cord at 1.5T: preliminary results

BACKGROUND AND PURPOSE

Recent studies suggest that pediatric subjects as old as 8-years-of-age may have difficulty with the ISNCSCI examinations. Our aim was to investigate DTI parameters of healthy spinal cord in children with noncervical IS for comparison with children with SCI and to prospectively evaluate reliability measures of DTI and to correlate the measures obtained in children with SCI with the ISNCSCI.

MATERIALS AND METHODS

Five controls with thoracic and lumbar IS and 5 children with cervical SCI were imaged twice by using a single-shot echo-planar diffusion-weighted sequence. Axial imaging was performed to cover the entire cervical spinal cord in controls. For the SCI subjects, 2 vertebral bodies above and below the injury were imaged. FA and D values were obtained at different levels of the cervical spinal cord. All subjects with SCI had undergone ISNCSCI clinical examinations. Statistical analysis was performed to access differences of the DTI indices between the controls and SCI subjects, reproducibility measurements, and correlations between DTI and ISNCSCI.

RESULTS

Subjects with SCI showed reduced FA and increased D values compared with controls. Test-retest reproducibility showed good ICC coefficients in all the DTI index values among controls (≥0.9), while the SCI group showed moderate ICC (≥0.77). There were statistically significant correlations between the various DTI indices and ISNCSCI scores.

CONCLUSIONS

Preliminary DTI indices in children were determined and showed good reproducibility. Reduced FA and increased D values were seen in children with SCI in comparison with controls and showed good clinical correlation with ISNCSCI examinations.

Implanted functional electrical stimulation hand system in adolescents with spinal injuries: an evaluation

OBJECTIVE

To study the utility and functional benefits of an implanted functional electrical stimulation (FES) system for hand grasp and release in adolescents with tetraplegia secondary to spinal cord injuries.

DESIGN

Intervention study with before-after trial measurement with each subject as his or her own control.

SETTING

Nonprofit pediatric orthopedic rehabilitation facility specializing in spinal cord injury.

PARTICIPANTS

A convenience sample of five adolescents between 16 and 18 years of age with C5 or C6 level tetraplegia at least 1 year after traumatic spinal cord injury. Key muscles for palmar and lateral grasp and release were excitable by electrical stimulation.

INTERVENTIONS

A multichannel stimulator/receiver and eight electrodes were surgically implanted to provide stimulated palmar and lateral grasp and release. In conjunction with implantation of the FES hand system, surgical reconstruction in the form of tendon transfers, tendon lengthenings and releases, and joint arthrodeses was performed to augment stimulated hand function. Rehabilitation of the tendon transfers and training in the use of the FES hand system were provided.

MAIN OUTCOME MEASURES

Measurements of pinch and grasp force, the Grasp and Release Test (GRT), and an assessment of six activities of daily living (ADL) were administered before implantation of the FES hand system and at regular follow-up intervals. Results of the stimulated response of individual muscles and surgical reconstruction were evaluated using standard and stimulated muscle testing techniques and standard assessment of joint range of motion. All subjects completed followup testing.

RESULTS

Lateral and palmar forces were significantly greater than baseline forces (p = .043). Heavy objects on the GRT could only be manipulated with FES, and FES increased the level of independence in 25 of 30 ADL comparisons (5 subjects, 6 activities) as compared to baseline. After training, FES was preferred in 21 of 30 comparisons over the typical means of task completion. Of the 40 electrodes implanted, 37 continue to provide excellent stimulated responses and all of the implanted stimulators have functioned without problems. The surgical reconstruction procedures greatly enhanced FES hand function by either expanding the workspace in which to utilize FES (deltoid to triceps transfer), stabilizing the wrist (brachioradialis to wrist extensor transfer), or stabilizing joints (intrinsic tenodesis transfer, FPL split transfer).

CONCLUSION

For five adolescents with tetraplegia, the combination of FES and surgical reconstruction provided active palmar and lateral grasp and release. Laboratory-based assessments demonstrated that the FES system increased pinch force, improved the manipulation of objects, and typically increased independence in six standard ADL as compared to pre-FES hand function. The study also showed that the five adolescents generally preferred FES for most of the ADL tested. Data on the benefits of the implanted FES hand system outside of the laboratory are needed to understand the full potential of FES.

Assessment of upper limb in tetraplegia: considerations in evaluation and outcomes research

This article briefly discusses several measurement tools for evaluating the upper limb of persons with tetraplegia. Muscle strength testing and electrodiagnostics are discussed as they relate to technique and usefulness for clinical trials. Standardized measures of hand function are reviewed; their limitations for clinical trials during acute spinal cord injury (SCI) care are acknowledged and their strengths for interventional studies and clinical trials during chronic phases of SCI care are defined. Recommendations are set forth for incorporating the International Classification for Surgery of the Hand in Tetraplegia motor and sensory examinations as adjuncts to the International Standards for Neurological Classification of SCI motor and sensory examinations and for further developing electrodiagnostic techniques as measurement tools for acute clinical trials. The Grasp and Release Test is described and recommended for clinical trials involving persons in the chronic stages of SCI. Lastly, we note that much work remains in the development, validation, and clinical deployment of an assessment of upper-limb function in SCI.

Development of an upper extremity FES system for individuals with C4 tetraplegia

The application of functional electrical stimulation (FES) to provide upper extremity function for individuals with C4 tetraplegia is under investigation. In this study, a FES system was designed that allowed one individual with complete C4 tetraplegia to coordinate stimulated lateral or palmar prehension with stimulated arm movements using contralateral shoulder position. The system consisted of percutaneous intramuscular electrodes implanted to muscles for hand grasp and release, supination, elbow flexion, and extension and arm adduction. Due to peripheral denervation, transposition and subsequent stimulation of the paralyzed latissimus dorsi muscle provided elbow flexion and transfer and stimulation of the paralyzed extensor carpi ulnaris muscle provided forearm supination. A suspended sling provided shoulder joint stability. The subject controlled stimulation proportionally using contralateral shoulder motion sensed by a position transducer. Control of stimulated hand grasp and release were coupled with stimulated arm motions so that hand-to-mouth activities could be accomplished with one motion of the contralateral shoulder. With this system, the subject was able to grasp a milk carton placed in the hand and lift and lower it from his mouth to drink from a short straw. He could also scoop a semisolid substance with an adapted spoon and lift and lower it from the work surface to his mouth to eat. The subject required assistance to place the milk carton or spoon in his hand and position the plate for scooping. Further investigation is needed to generate the necessary arm movements to make completion of these tasks possible without assistance and to expand the range of activities possible with the FES system.

Effect of bracing on paralytic scoliosis secondary to spinal cord injury

BACKGROUND

The incidence of paralytic scoliosis subsequent to acquired spinal cord injury (SCI) has been reported to range from 46% to 97% in patients injured before the adolescent growth spurt.

OBJECTIVE

The purpose of this report is to review early bracing of children with SCI as a means of preventing or delaying surgical fusion.

METHODS

Patient records from January 1996 to December 2001 from the Shriners Hospitals for Children-Philadelphia were retrospectively reviewed; 123 patients met the inclusion criteria of cervical or thoracic SCI prior to skeletal maturity. Patients were divided into 5 groups based on their radiographic curve severity at presentation, and then they were subdivided into a group that was managed with prophylactic bracing and a group that was not braced. End-points included completion of bracing regimen, surgery, or cessation of growth.

RESULTS

Forty-two patients presented with a curve < 10 degrees, 29 of whom were braced, and 13 who were not. Of the braced group, 13 (45%) went on to surgery, whereas 10 (77%) of the nonbraced group had surgical correction (P = 0.03). Of the patients who were initially braced, the average time to surgery was 8.5 years, whereas that for the nonbraced group was 4.2 years (P = 0.002). A similar trend was seen in the patients who presented with an initial curve between 11 degrees and 20 degrees (P < 0.001). There was no significant difference between time to surgery for the braced and nonbraced patient groups at higher (> 20 degrees) initial curve presentations.

CONCLUSION

Bracing of children with SCI before significant curve formation (< 20 degrees) delays the time to surgical correction of the deformity as it progresses. At smaller curves (< 10 degrees), bracing may even prevent the need for surgery. As curve size increases (> or = 20 degrees), bracing seems to play a limited role, because it does not seem to prevent surgery or delay time to surgical correction.

Neuromuscular scoliosis in children with spinal cord injury

BACKGROUND

The prevalence of neuromuscular scoliosis in children with spinal cord injury (SCI) is high. Published reports suggest that age at time of injury is the most important determinant. No studies have evaluated neurological characteristics using standardized methods to determine if they are strong predictors of scoliosis.

OBJECTIVE

To test the hypothesis that neurological level, motor score, and injury severity are strong predictors of neuromuscular scoliosis.

METHODS

Two hundred seventeen children were evaluated using the testing guidelines of the International Standards for Neurological Classification of Spinal Cord Injury. Cobb angles were calculated from plain radiographs as a measure of scoliosis. Multivariate analysis with statistical selection was used to determine predictors of worst Cobb angle and spinal fusion. The odds of having a spine fusion for subjects with at least 2-year follow-up and injured prior to (n=16) and after (n=91) 12 years of age were calculated.

RESULTS

The hypothesis was not supported. Although there was a very high prevalence (100%) of scoliosis in the study sample, age at time of injury was the only predictor of worst curve (P < .0001) and spine fusion (P < .007). The calculated odds ratio demonstrated that children injured <12 years were 3.7 times more likely to have a spine fusion (95% CI, 0.31-44.64).

CONCLUSION

There is a very high prevalence of neuromuscular scoliosis in pediatric SCI. Neurological level, motor level, and severity of injury are not strong predictors. Age is the only predictor of worst curve and spine fusion.

Implantation of the Freehand System during initial rehabilitation using minimally invasive techniques

STUDY DESIGN

Series of four single subjects with and without intervention design.

OBJECTIVES

To describe a minimally invasive surgical technique used to implant the Freehand System during initial spinal cord injury (SCI) rehabilitation and to report rehabilitation outcomes of four recently injured adolescents using the Freehand System.

SETTING

Nonprofit children's hospital specializing in orthopedic and SCI care.

METHODS

Four subjects with C5 tetraplegia between 13 and 16 years of age and between 9 and 16 weeks following traumatic SCI underwent implantation of the Freehand System using minimally invasive surgical techniques. Outcomes on muscle strength, pinch force, hand function, performance of activities of daily living and satisfaction with and without the Freehand System were collected.

RESULTS

Each subject was successfully implanted with the Freehand System without perioperative complications and employed the Freehand System during therapy services and ad lib on the rehabilitation floor. At the last follow-up, every subject remained a motor candidate for the Freehand System. With the Freehand System, average lateral and palmar pinch force was 1.8 and 1.6 kg respectively; average pinch force without functional electrical stimulation (FES) was 0.29 kg. With the Freehand System, three subjects improved their rate of performance on The Upper Extremity Capabilities Questionnaire. All subjects increased their level of independence on The Quadriplegia Index of Function. On the Canadian Occupational Performance Measure (COPM) with the Freehand System, average performance and satisfaction scores improved for every patient. Three of the four subjects continued to use the system at home.

CONCLUSION

This case series demonstrates that the Freehand System can vastly improve hand function and performance of rehabilitation activities within days after a minimally invasive implant procedure during initial SCI rehabilitation. Satisfaction with the Freehand System beyond initial rehabilitation is evidenced by continued use at home.

Diagnostic accuracy of diffusion tensor imaging for pediatric cervical spinal cord injury

STUDY DESIGN

Cross-sectional non-experimental study.

OBJECTIVES

To examine diagnostic accuracy of diffusion tensor imaging (DTI) for pediatric spinal cord injury (SCI).

SETTING

Pediatric Orthopedic Hospital.

METHODS

Thirty-five subjects, 10 SCI and 25 controls, mean age 13.38 years underwent two scans with 3.0 T MR scanner. Fractional anisotropy (FA), axial diffusivity (AD) and radial diffusivity (RD) values were calculated. Subjects with SCI underwent examination of muscle strength, sensation and sacral sparing. Mean and s.d. values for FA, AD and RD were compared by group (controls, SCI with sacral sparing, SCI without sacral sparing) using analysis of variance for repeated measures. Comparisons were also made of DTI values at the injury site to values from cervical regions outside of the injury site. Specificity, sensitivity, receiver operating characteristics area under the curve (ROC AUC) and corresponding 95% confidence intervals were calculated. Resampling methods were used to validate the estimates from the final models.

RESULTS

FA values differed among SCI subjects with intact sacral sparing, absent sacral sparing and controls, P<0.003 (adjusted). DTI values in combination showed the strongest diagnostic accuracy for predicting the presence of anal contraction (AD, RD; ROC AUC=0.90), deep anal pressure (FA; ROC AUC=0.88), S4-5 sensation (FA, RD; ROC AUC=0.93), motor level (FA, AD, RD; ROC AUC=0.92) and MRI level (FA, AD, RD; ROC AUC=0.92). Bootstrap and Jackknife median values indicated consistency of the parameter estimates.

CONCLUSION

The predictive accuracy of DTI for sacral sparing end points and motor and MRI level of injury was good to strong.

Implanted functional electrical stimulation: an alternative for standing and walking in pediatric spinal cord injury

STUDY DESIGN

Post intervention, repeated measures design, comparing two interventions.

SETTING

Orthopedic pediatric hospital specializing in spinal cord injury.

METHODS

Nine subjects, ages 7-20 years, received an eight-channel implanted lower extremity functional electrical stimulation (FES) system for standing and walking. Electrodes were placed to stimulate hip and knee extension, and hip abduction and adduction. Standing and walking were achieved through constant stimulation to the implanted muscles, allowing a swing through gait pattern with an assistive device. After training with FES and long leg braces (LLB), subjects were tested in eight upright mobility activities, which were scored based upon completion time and level of independence.

RESULTS

Seven subjects completed data collection. These subjects completed four activities faster (P<0.02) and five activities more independently (P<0.025) with FES as compared to LLB. Transitions between sitting and standing, which were scored in isolation for two mobility activities, were achieved faster and with more independence with FES. In addition, subjects reported preferring FES for the majority of activities. No activity required more time or more assistance to complete with FES as compared to LLB.

CONCLUSION

The implanted FES system provided these subjects with enhanced functional abilities over traditional LLB and decreased the need for physical assistance by a caregiver, suggesting that it is a realistic alternative for upright mobility in a pediatric population with spinal cord injury.

Effects of cycling and/or electrical stimulation on bone mineral density in children with spinal cord injury

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To determine the effect of cycling and/or electrical stimulation on hip and knee bone mineral density (BMD) in children with spinal cord injury (SCI).

SETTING

Children's hospital specializing in pediatric SCI.

METHODS

A total of 30 children, aged 5-13 years, with chronic SCI were randomized to one of three interventions: functional electrical stimulation cycling (FESC), passive cycling (PC), and non-cycling, electrically stimulated exercise (ES). Each group exercised for 1 h, three times per week for 6 months at home. The hip, distal femur and proximal tibia BMD were examined via dual-energy X-ray absorptiometry (DXA) pre- and post-intervention.

RESULTS

In all, 28 children completed data collection. The FESC group exhibited increases in hip, distal femur and proximal tibia BMD of 32.4, 6.62 and 10.3%, respectively. The PC group exhibited increases at the hip (29.2%), but no change at the distal femur (1.5%) or proximal tibia (-1.0%). The ES group had no change at the hip (-0.24%) and distal femur (3.3%), but a loss at the proximal tibia (-7.06%). There were no differences between groups or within groups over time. Significant negative correlations were found between baseline BMD and the amount of BMD change.

CONCLUSION

Although not achieving statistical significance, hip BMD changes observed were greater than the reported 0.9-10% gains after exercise for children with and without disability. Thus, cycling with and without electrical stimulation may be beneficial for skeletal health in pediatric SCI, but further research is needed with a larger sample size.

An examination of the PROMIS(®) pediatric instruments to assess mobility in children with cerebral palsy

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS(®)) provides adult and pediatric self-report measures of health-related quality of life designed for use across medical conditions and the general population. The purpose of this study was to examine the feasibility and validity of the PROMIS(®) Pediatric Short Form and computer-adaptive test (CAT) mobility measures in children with cerebral palsy (CP).

METHODS

Eighty-two children with CP completed self-report (PROMIS(®) Mobility Short Form, PROMIS(®) Mobility CAT, Pediatric Quality of Life Inventory™) and performance-based assessments of mobility (Timed Up and Go, Gross Motor Function Measure). Parents provided three proxy reports of child mobility (Pediatric Outcomes Data Collection Instrument, Functional Assessment Questionnaire, Shriners Hospitals for Children CP-CAT). Validity of PROMIS(®) instruments was examined through correlations with other measures and "known groups" analyses determined by Gross Motor Function Classification System (GMFCS).

RESULTS

On average, the PROMIS(®) CAT required less than seven items and 2 minutes to administer. Both PROMIS(®) measures showed moderate to high correlations with child- and parent-proxy report of child mobility; correlations with performance-based measure were small for the PROMIS(®) Short Form and non-significant for the PROMIS(®) CAT. All measures except for the PROMIS(®) CAT were able to distinguish between GMFCS categories.

CONCLUSIONS

Results support the convergent and discriminant validity of the pediatric PROMIS(®) Mobility Short Form in children with CP. The PROMIS(®) Mobility CAT correlates well with child report and parent report of mobility but not with performance-based measures and does not differentiate between known mobility groups.

Diffusion tensor imaging of the normal pediatric spinal cord using an inner field of view echo-planar imaging sequence

BACKGROUND AND PURPOSE

DTI in the brain has been well established, but its application in the spinal cord, especially in pediatrics, poses several challenges. The small cord size has inherent low SNR of the diffusion signal intensity, respiratory and cardiac movements induce artifacts, and EPI sequences used for obtaining diffusion indices cause eddy-current distortions. The purpose of this study was to 1) evaluate the accuracy of cervical spinal cord DTI in children using a newly developed iFOV sequence with spatially selective 2D-RF excitations, and 2) examine reproducibility of the DTI measures.

MATERIALS AND METHODS

Twenty-five typically developing subjects were imaged twice using a 3T scanner. Axial DTI images of the cervical spinal cord were acquired with this sequence. After motion correction, DTI indices were calculated using regions of interest manually drawn at every axial section location along the cervical spinal cord for both acquisitions. Various DTI indices were calculated: FA, AD, RD, MD, RA, and VR. Geometric diffusion measures were also calculated: Cp, Cl, and Cs.

RESULTS

The following average values for each index were obtained: FA = 0.50 ± 0.11; AD = 0.97 ± 0.20 × 10(-3)mm(2)/s; RD = 0.41 ± 0.13 × 10(-3)mm(2)/s; MD = 0.59 ± 0.15 × 10(-3)mm(2)/s; RA = 0.35 ± 0.08; VR = 0.03 ± 0.00; Cp = 0.13 ± 0.07; Cl = 0.29 ± 0.09; and Cs = 0.58 ± 0.11. The reproducibility tests showed moderate to strong ICC in all subjects for all DTI parameters (ICC>0.72).

CONCLUSIONS

This study showed that accurate and reproducible DTI parameters can be estimated in the pediatric cervical spinal cord using an iFOV EPI sequence.