Respiratory functional and motor control deficits in children with spinal cord injury

Research Priorities of the Pediatric Spinal Cord Injury Population: An International Insight for Rehabilitation Care

BACKGROUND

Although feedback from people with adult-onset spinal cord injury (SCI) has been considered for new rehabilitation programs, little is known about the priorities of the pediatric-onset SCI population. This study describes and compares health and life (H&L) domain research priorities of youth with pediatric-onset SCI and their parents/caregivers.

METHODS

A cross-sectional survey, designed by the Pan-European Paediatric Spinal Cord Injury (PEPSCI) Collaboration, was performed at six European countries. Dyad data from 202 participants, youth with pediatric-onset SCI (n = 101) and their parents/caregivers (n = 101), were analyzed with the PEPSCI H&L domain surveys.

RESULTS

The cohort was composed of 8 to 12-year-olds (30.7%), 13 to 17-year-olds (38.6%), and 18 to 25-year-olds (30.7%). The top three H&L domain research priorities reported by parents/caregivers of 8 to 12-year-olds were "walking/ability to move" (91%), "bladder" function (90%), and "general health/feel" (89%), compared with "physical function" (93%), "general health/feel" (90%), and "walking/ability to move" (89%) rated by parents/caregivers of 13 to 25-year-olds. "Bowel" function (85%), "leg/foot movement" (84%), and "bladder" function (84%) were reported as priorities by 13 to 25-year-olds, whereas "physical function" (84%), "experience at school" (83%), and "general mood" were highlighted by 8 to 12-year-olds. The top 10 priorities preferred by 13 to 25-year-olds when compared with the top 10 priorities reported by their parents/caregivers, included problems related to "bowel" and "pain."

CONCLUSIONS

Health domain research priorities were highlighted by 13 to 25-year-olds, compared with their parents/caregivers who equally identified H&L domains. This survey will aid health care and clinical research organizations to engage stakeholders to implement a comprehensive research strategy for the pediatric SCI population.

Development of a rocking chair for use by children with spinal cord injuries

PURPOSE

Activity-based locomotor training improves intrinsic trunk control in children with spinal cord injury (SCI). To reinforce these improvements, there is a need to develop community integration activities to allow a patient to apply the retrained nervous system at home. One activity that has been explored is rocking in a rocking chair. This paper describes the design, fabrication, and evaluation of a rocking chair for children with SCI.

MATERIALS AND METHODS

The Quality Function Deployment (QFD) design process was used. Fundamental needs and features for the rocking chair were defined in a focus group with experienced therapists, and needs were then rated for importance. A House of Quality (HOQ) matrix was developed to correlate needs with design features, and a prototype design was generated. Virtual motion studies and finite element analysis (FEA) were utilized to assess the design. The chair was fabricated and physical testing was performed, including tipping and static and dynamic load assessments.

RESULTS AND CONCLUSIONS

The needs identified through the QFD process were categorized into (1) safety, (2) therapeutic, (3) practical and aesthetic, and (4) data to track chair use. Features selected to meet these needs include safety stops, padding, straps, a stable base, armrests, adjustable footrest, and sensors to capture rocking data. FEA showed a factor of safety (FOS) > 5. Physical testing confirmed physical integrity, load-bearing capacity, and stability of the prototype glider rocking chair. The prototype provides a safe tool for further investigation of rocking for promotion of trunk muscle activation in children with SCI.

Spinal Cord Injury at Birth, Expected Medical and Health Complexity in Chronic Injury Guided Anew by Activity-Based Restorative Therapy: Case Report

As infancy is characterized by rapid physical growth and critical periods of development, disruptions due to illness or disease reveal vulnerability associated with this period. Spinal cord injury (SCI) has devastating consequences at any age, but its onset neonatally, at birth, or within the first year of life multiplies its impact. The immediate physical and physiological consequences are obvious and immense, but the effects on the typical trajectory of development are profound. Activity-based restorative therapies (ABRT) capitalize on activity-dependent plasticity of the neuromuscular system below the lesion and when provided to children with SCI aim to improve the child's neuromuscular capacity, health and quality of life. This is a report of an infant with a cervical SCI at birth resulting in paralysis of leg and trunk muscles and paresis of arm and hands who was enrolled in an ABRT program at 3 years of age. After 59 sessions of ABRT, the child demonstrated significant improvements in trunk control and arm function, as well as social and emotional development. Despite the chronicity of injury and low expectations for improvement with therapeutic interventions, ABRT had a positive impact on the child's physical capacity and provided benefits across multiple developmental domains.

A Systematic Review of the Scientific Literature for Rehabilitation/Habilitation Among Individuals With Pediatric-Onset Spinal Cord Injury

Objectives

To conduct a systematic review to examine the scientific literature for rehabilitation/habilitation among individuals with pediatric-onset spinal cord injury (SCI).

Methods

A literature search of multiple databases (i.e., PubMed/MEDLINE, CINAHL, EMBASE, PsychINFO) was conducted and was filtered to include studies involving humans, published as full-length articles up to December 2020, and in English. Included studies met the following inclusion criteria: (1) ≥50% of the study sample had experienced a traumatic, acquired, nonprogressive spinal cord injury (SCI) or a nontraumatic, acquired, noncongenital SCI; (2) SCI onset occurred at ≤21 years of age; and (3) sample was assessed for a rehabilitation/habilitation-related topic. Studies were assigned a level of evidence using an adapted Sackett scale modified down to five levels. Data extracted from each study included author(s), year of publication, country of origin, study design, subject characteristics, rehabilitation/habilitation topic area, intervention (if applicable), and outcome measures.

Results

One hundred seventy-six studies were included for review (1974-2020) with the majority originating from the United States (81.3%). Most studies were noninterventional observational studies (n = 100; 56.8%) or noninterventional case report studies (n = 5; 2.8%). Sample sizes ranged from 1 to 3172 with a median of 26 (interquartile range [IQR], 116.5). Rehabilitation/habilitation topics were categorized by the International Classification of Functioning, Disability and Health (ICF); most studies evaluated ICF Body Function. There were 69 unique clinical health outcome measures reported.

Conclusion

The evidence for rehabilitation/habilitation of pediatric-onset SCI is extremely limited; nearly all studies (98%) are level 4-5 evidence. Future studies across several domains should be conducted with novel approaches to research design to alleviate issues related to sample sizes and heterogeneity.

Health and LifeDomain ResearchPriorities in Children, Adolescents and Young Adults With Pediatric-Onset Spinal Cord Injury: A National Cross-Sectional Survey in England

Background

Although feedback from people with adult-onset spinal cord injury (SCI) has been considered in developing research programs, little is known about pediatric-onset SCI priorities.

Objectives

To describe the health and life (H&L) domain research priorities of youth with pediatric-onset SCI living in England.

Methods

Youth with pediatric-onset SCI (≥6 months) were recruited from five English rehabilitation centers and invited with their parents/caregivers to complete the age-appropriate surveys designed by the Pan-European Paediatric Spinal Cord Injury (PEPSCI) collaboration.

Results

A total of 73 surveys were received (32 from participants with SCI and 41 from their parents/caregivers), providing information on 47 individuals with SCI: 2- to 7-year-olds (29.8%), 8- to 12-year-olds (19.2%), 13- to 17-year-olds (17.0%), and 18 to 25-year-olds (34.0%). The top three research priorities reported by parents/caregivers of 2- to 12-year-old and 13- to 25-year-olds were pain (81%/89%), physical function (91%/83%) and health care access (78%/78%). Eighty-nine percent of 8- to 12-year-olds emphasized schooling, peer relationships, and general mood as their research priorities. The top three research priorities for Health or Life domains reported by 13- to 25-year-olds included spasms (95%), pain (91%), pressure injuries (91%), health care access (83%), physical function (78%), and daily personal needs (74%).

Conclusion

Although there should be an emphasis on addressing important life domain issues for 8- to 12-year-olds with SCI, adolescents and young adults mostly prioritized health domain research priorities in addition to health care access. This survey will aid health care and clinical research organizations to engage stakeholders to implement a comprehensive SCI research strategy in England for the pediatric population.

Respiratory Syncytial Virus-Associated Hospitalizations in Children With Neurological Disorders, 2006-2015

BACKGROUND

We quantified the risk of respiratory syncytial virus (RSV) hospitalizations and severe outcomes among children with neurological disorders.

METHODS

We estimated RSV-specific and RSV-associated hospitalization rates using International Classification of Diseases, Ninth Revision (ICD-9) codes from 2 insurance claims IBM MarketScan Research Databases (Commercial and Multi-State Medicaid) from July 2006 through June 2015. For comparison, a simple random sample of 10% of all eligible children was selected to represent the general population. Relative rates (RRs) of RSV hospitalization were calculated by dividing rates for children with neurological disorders by rates for children in the general population by age group and season.

RESULTS

The RSV-specific hospitalization rate for children with any neurological condition was 4.2 (95% confidence interval [CI]: 4.1, 4.4) per 1000 person-years, and the RSV-associated hospitalization rate was 7.0 (95% CI: 6.9, 7.2) per 1000 person-years among children <19 years of age. Among privately insured children, the overall RR of RSV hospitalization in children with neurological disorders compared with the general population was 10.7 (95% CI: 10.0, 11.4) for RSV-specific hospitalization and 11.1 (95% CI: 10.5, 11.7) for RSV-associated hospitalizations. Among children in Medicaid, the RSV-specific hospitalization RR was 6.1 (95% CI: 5.8, 6.5) and the RSV-associated hospitalization RR was 6.4 (95% CI: 6.2, 6.7) compared with the general population.

CONCLUSIONS

Our population-based study of children with neurological disorders found that the risk of RSV hospitalization was 6 to 12 times higher among children with neurological disorders than among the general pediatric population. These findings should be considered when determining who should be targeted for current and future RSV interventions.

Impact of Activity-Based Therapy on Respiratory Outcomes in a Medically Complex Child

Introduction: Activity-based therapies (ABTs) focus on activating the neuromuscular system below the level of spinal cord injury (SCI) promoting neuromuscular capacity. Case description: A 2 year 7 month old with history of prematurity at 29 weeks, neonatal epidural abscess, resultant cervical SCI, respiratory failure, and global developmental delays presented for enrollment in an outpatient activity-based therapy program. Upon presentation to this program, he required nighttime mechanical ventilation via tracheostomy and daytime suctioning. He could not perform any age-appropriate activities and was described by his mother as ‘present’, neither engaged nor attentive. During and after 7 months of participation in ABTs including locomotor training and neuromuscular electrical stimulation, the patient demonstrated unexpected changes in his respiratory status leading to ventilator weaning with concomitant improvements in head and trunk control, participation, development, and quality of life. Discussion: ABT was not only safe for a medically complex child, but also this intervention had a remarkable effect on unresolved respiratory capacity and a more widespread impact on other functions as well as development. A child with a chronic, severe SCI demonstrated positive and impactful improvements in health, functional status, and quality of life during an episode of ABT.

Single and sequential voluntary cough in children with chronic spinal cord injury

We investigated the impact of spinal cord injury (SCI) on cough capacity in 10 children (Mean ± SD, age 8 ± 4 years) and compared it to 15 typically developing children (age 8 ± 3 years). Participants underwent spirometry, single and sequential cough assessment with surface-electromyography from respiratory muscles. Inspiratory phase duration, inspiratory phase peak flow, inspiratory phase rise time, compression phase duration, expiratory phase rise time, expiratory phase peak airflow (EPPF) and cough volume acceleration (CVA) parameters of single and sequential cough were measured. Root mean square (RMS) values of right pectoralis-major, intercostal, rectus-abdominus (RA), and oblique (OB) muscles were calculated and mean of three trials were compared. The significance criterion was set at P < 0.05. The SCI group produced significantly lower lung volumes, EPPF, CVA, and RMS values of RA and OB during expiratory phases of single and sequential coughs. The decrease in activation in expiratory muscles in the SCI group accounts for the impaired expiratory flow and may contribute to risk of respiratory complications.

Spinal cord injury in infancy: activity-based therapy impact on health, function, and quality of life in chronic injury

Introduction

Spinal cord injury (SCI) in infancy magnifies the complexity of a devastating diagnosis. Children injured so young have high incidences of scoliosis, hip dysplasia, and respiratory complications leading to poor health and outcomes. We report the medical history, progression of rehabilitation, usual care and activity-based therapy, and outcomes for a child injured in infancy. Activity-based therapy (ABT) aims to activate the neuromuscular system above and below the lesion through daily, task-specific training to improve the neuromuscular capacity, and outcomes for children with acquired SCI.

Case presentation

A 3-month-old infant suffered a cervical SCI from a surgical complication with resultant tetraplegia. Until age 3, her medical complications included scoliosis, kyphosis, and pneumonia. Even with extensive physical and occupational therapy, she was fully dependent on caregivers for mobility and unable to roll, come to sit, sit, stand or walk. She initiated ABT at ~3 years old, participating for 8 months. The child’s overall neuromuscular capacity improved significantly, especially for head and trunk control, contributing to major advances in respiratory health, novel engagement with her environment, and improved physical abilities.

Discussion

From injury during infancy until 3 years old, this child’s health, abilities, and complications were consistent with the predicted path of early-onset SCI. Due to her age at injury, severity and chronicity of injury, she demonstrated unexpected, meaningful changes in her neuromuscular capacity during and post-ABT associated with improved health, function and quality of life for herself and her caregivers.