Overview of adult outcomes in pediatric-onset spinal cord injuries: implications for transition to adulthood

Anxiety and Depression in Pediatric-Onset Traumatic Spinal Cord Injury: A Systematic Review

BACKGROUND

Traumatic spinal cord injury (TSCI) is a debilitating neurological condition with significant long-term consequences on the mental health and well-being of affected individuals. We aimed to investigate anxiety and depression in individuals with pediatric-onset TSCI.

METHODS

PubMed, Scopus, and Web of Science databases were searched from inception to December 20th, 2022 following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, and studies were included according to the eligibility criteria.

RESULTS

A total of 1013 articles were screened, and 18 studies with 4234 individuals were included in the final review. Of these, 1613 individuals (38.1%) had paraplegia, whereas 1658 (39.2%) had tetraplegia. A total of 1831 participants (43.2%) had complete TSCI, whereas 1024 (24.2%) had incomplete TSCI. The most common etiology of TSCI with 1545 people (36.5%) was motor vehicle accidents. The youngest mean age at the time of injury was 5.92 ± 4.92 years, whereas the oldest was 14.6 ± 2.8 years. Patient Health Questionnaire-9 was the most common psychological assessment used in 9 studies (50.0%). Various risk factors, including pain in 4 studies (22.2%), reduced sleep quality, reduced functional independence, illicit drug use, incomplete injury, hospitalization, reduced quality of life, and duration of injury in 2 (11.1%) studies, each, were associated with elevated anxiety and depression.

CONCLUSIONS

Different biopsychosocial risk factors contribute to elevated rates of anxiety and depression among individuals with pediatric-onset TSCI. Individuals at risk of developing anxiety and depression should be identified, and targeted support should be provided. Future large-scale studies with long-term follow-up are required to validate and extend these findings.

Feasibility and Acceptability of a Codesigned Health Care Transition Intervention for Young People With Spinal Cord Injuries

Background

Due in part to medical complications, adults with a pediatric onset spinal cord injury (SCI) are at higher risk of experiencing dissatisfaction with life and lower perceived physical health when compared to their peers with no disability. To support the prevention of medical complications, young people with SCI must successfully transition to adult health care. Health care transition (HCT) interventions can support young people with chronic conditions in their move to adult health care.

Objectives

To evaluate the feasibility and acceptability of a web-based HCT intervention codesigned with young people with SCI and parents/caregivers.

Methods

Semi-structured individual interviews were conducted online with young people with SCI and parents/caregivers who transitioned or were preparing for the transition from pediatric to adult health care. Interviews were also conducted with health care professionals. The interviews were analyzed using a hybrid deductive and inductive qualitative content analysis process. Feasibility and acceptability were measured using Bowen and colleagues' framework, which includes eight focus areas: acceptability, demand, implementation, practicality, adaption, integration, expansion, and limited efficacy.

Results

Overall, participants responded positively to the intervention and believed that it would be useful to young people with SCI and parents/caregivers. Two areas of Bowen et al.'s framework, implementation and integration, require further consideration in terms of how to embed the intervention into the current transition process.

Conclusion

This study found the HCT intervention to be an innovative approach to support young people with SCI and their parent/caregivers that demonstrates promise in the areas of feasibility and acceptability.

Predictors of participation and quality of life following major traumatic injuries in childhood: a systematic review

OBJECTIVE

Review the literature on predictors of participation and quality of life in children and young people who sustained a traumatic brain injury (TBI), spinal cord injury (SCI), and/or multi-trauma in a motor vehicle or other accident or trauma.

DESIGN

This systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The protocol was registered on PROSPERO (registration number CRD42020131698). Electronic databases were searched for studies published between January 2000 and August 2020. Prospective and retrospective cohort studies were considered and risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool.

RESULTS

The search yielded 5771 articles of which 30 studies met the inclusion criteria. Nineteen studies included patients with TBI and 11 with SCI. No studies of patients with multi-trauma met criteria. Evidence was found for associations with various factors (e.g., injury severity, level of education, mental health problems), although these findings are limited due to the quality of the studies (5 studies moderate and 25 high risk of bias).

CONCLUSION

Research on predictors of participation and quality of life following major traumatic injuries in childhood is lacking. More methodologically sound prospective, longitudinal studies are needed across different injury groups to further elucidate predictors of outcome.IMPLICATIONS FOR REHABILITATIONWhile long-term participation and quality of life is influenced by injury characteristics (i.e., injury severity), a number of potential modifiable factors can be targeted to improve outcomes following traumatic injuries in childhood.Young people should be provided with support to stay in school and pursue further education.Early intervention and prevention of mental health problems may improve long-term outcomes.Better management of ongoing medical problems and greater support for functional independence may improve participation.

Comparison of disability and quality of life between patients with pediatric and adult onset paraplegia

OBJECTIVE

To investigate the factors that affect disability and quality of life in patients with spinal cord injuries (SCIs) and to compare the degree of disability and quality of life in patients with SCI according to over and under 18 years of age when their injury occurred.

DESIGN

Cohort study.

SETTING

Two academic hospitals in Istanbul, Turkey.

PARTICIPANTS

Forty patients with SCI were included in this study. Group 1 included 20 patients with SCI who were younger than 18 years of age when their injury occurred, Group 2 included 20 patients who were older than 18 years of age when their injury occurred.

OUTCOME MEASURES

Patients' demographics, duration of SCI and degree of disability were assessed using the Craig Handicap Assessment and Reporting Technique (CHART). Quality of life was assessed using the World Health Organization Quality of Life Scale Short Form (WHOQOL-Bref). Depression was assessed using the Beck Depression Inventory (BDI).

RESULTS

Although there was no significant difference between the BDI scores and CHART scores of the two groups, environment domain scores in the WHOQOL-Bref were significantly higher in Group 2 than in Group 1 (P<0.05). No significant correlation was found between age of SCI onset, disease duration, ASIA scores, depression scores, total CHART scores for all patients.

CONCLUSION

Adaptation to environment was significantly better in those who suffered SCI during adulthood than in pediatric patients with SCI. Disability level was not associated with age of disease onset, disease duration, neurological status, depression level.

Spinal cord injury in pediatric age in Spain. Reality of a national reference center

The aim of this study was to analyze the incidence and the main characteristics of ambulant children with spinal cord injury (SCI) treated at the Unit of Biomechanics and Technical Assistance, at the National Spinal Cord Injury Hospital in Toledo, Spain. To date, there are no detailed studies on the effects of this disease in children regarding their walking ability.

MATERIAL AND METHODS

A retrospective study was performed including all patients attending the unit between January 2006 and December 2013, who were aged 18 years or younger and who were outpatients able to walk independently for at least 10 m, with or without technical aids.

RESULTS

Forty-eight patients were included in this study (25 males and 23 females) aged between 2 and 18 years (mean age, 12 ± 2.31 years). The etiology of SCI ranged between congenital (33.33%), traumatic (29.16%), and neoplastic (8.33%), and the level of injury varied between cervical (31.25%), lumbar (29.16%), a non-spinal origin (20.83%), dorsal (16.66%), and sacral (2.08%). The mean score on the Barthel Index was 82.61, the mean value of the Functional Independence Measure (FIM) locomotion score was 6.4, and 29 patients did not require the use of walking aids (WISCI 20).

CONCLUSION

The findings of this study contribute to the knowledge regarding the situation of children with SCI in Spain. The incidence of pediatric SCI is very low; however, the provision of care remains a personal and social challenge.

Rehabilitation in transverse myelitis

The consequences of neurologic injuries related to transverse myelitis (TM) are long-lasting and require rehabilitative interventions in about two-thirds of cases. Because numerous neural repair mechanisms are dependent on maintenance of an optimal amount of activity both above and below the injury level, rehabilitation and exercise are useful not only for compensatory functional purposes but also as tools in neural system restoration. The application of established neurophysiologic principles to post-TM rehabilitation has substantial impact on optimizing residual functional capabilities while facilitating the processes of central plasticity and reorganization of sensory and motor programming. The process of neurorehabilitation thereby serves both to treat the patient with TM and to help physicians interrogate and dissect the mechanisms involved in spinal cord injury, neuroprotection, and, ultimately, recovery. Post-TM rehabilitation is lifelong and should be integrated into daily living in a home setting as part of the global management of paralysis, a chronic condition with significant comorbidities.

Spinal cord injuries in children and adolescents

This chapter provides an overview of spinal cord injuries (SCI) in children and adolescents, including epidemiology, medical and musculoskeletal complications, rehabilitation and psychosocial aspects. Males are more commonly affected than females during adolescence; however, as the age at injury decreases, the preponderance of males becomes less marked, and by 3 years of age the number of females with SCIs equals that of males. The neurologic level and degree of completeness varies with age; among children injured prior to 12 years of age approximately two-thirds are paraplegic and approximately two-thirds have complete lesions. Among adolescents, approximately 50% have paraplegia and 55% have complete lesions. Management of pediatric-onset SCI should be family centered and developmentally based, responsive to the dynamic changes that occur during growth and development. Distinctive anatomical and physiological features of children and adolescents, along with growth and development, are responsible for unique manifestations and complications of pediatric SCI. SCI without radiological abnormalities (SCIWORA), birth injuries, lap-belt injuries, upper cervical injuries, and the delayed onset of neurological deficits are relatively unique to pediatric SCI. Children who sustain their SCI before puberty experience a higher incidence of musculoskeletal complications, such as scoliosis and hip dislocation.

The German Version of the Satisfaction With Life Scale (SWLS)

The Satisfaction with Life Scale (SWLS) is the most commonly used measure for life satisfaction. Although there are numerous studies confirming factorial validity, most studies on dimensionality are based on small samples. A controversial debate continues on the factorial invariance across different subgroups. The present study aimed to test psychometric properties, factorial structure, factorial invariance across age and gender, and to deliver population-based norms for the German general population from a large cross-sectional sample of 2519 subjects. Confirmatory factor analyses supported that the scale is one-factorial, even though indications of inhomogeneity of the scale have been detected. Both findings show invariance across the seven age groups and both genders. As indicators of the convergent validity, a positive correlation with social support and negative correlation with depressiveness was shown. Population-based norms are provided to support the application in the context of individual diagnostics.

Ongoing walking recovery 2 years after locomotor training in a child with severe incomplete spinal cord injury

BACKGROUND AND PURPOSE

The authors previously reported on walking recovery in a nonambulatory child with chronic, severe, incomplete cervical spinal cord injury (SCI) after 76 sessions of locomotor training (LT). Although clinical measures did not predict his recovery, reciprocal patterned leg movements developed, affording recovery of independent walking with a reverse rolling walker. The long-term functional limitations and secondary complications often associated with pediatric-onset SCI necessitate continued follow-up of children with SCI. Therefore, the purpose of this case report is to describe this child's walking function and musculoskeletal growth and development during the 2 years since his participation in an LT program and subsequent walking recovery.

CASE DESCRIPTION

Following LT, the child attended elementary school as a full-time ambulator. He was evaluated 1 month (baseline), 1 year, and 2 years after LT. Examination of walking function included measures of walking independence, gait speed and spatiotemporal parameters, gait kinematics, and daily step activity. Growth and development were assessed by tracking his height, weight, incidence of musculoskeletal complications, and gross motor task performance.

OUTCOMES

Over the 2 years, the child continued to ambulate independently with a reverse rolling walker, increasing his fastest gait speed. Spatiotemporal and kinematic features of his walking improved, and daily step activity increased. Height and weight remained on their preinjury trajectory and within age-appropriate norms. The child experienced only minor musculoskeletal complications. Additionally, he gained the ability to use reciprocal patterned leg movements during locomotor tasks such as assisted stair climbing and independent tricycle pedaling.

CONCLUSIONS

Two years after recovery of walking, this child with incomplete SCI had maintained and improved his walking function and experienced age-appropriate growth and development.

Return to work following spinal cord injury: a review

PURPOSE

To review literature on return to work (RTW) and employment in persons with spinal cord injury (SCI), and present employment rates, factors influencing employment, and interventions aimed at helping people with SCI to obtain and sustain productive work.

METHODS

A systematic review for 2000 - 2006 was carried out in PubMed/Medline, AMED, (ISI) Web of Science, EMBASE, CINAHL, PsycInfo and Sociological abstracts database. The keywords 'spinal cord injuries', 'spinal cord disorder', 'spinal cord lesion' or 'spinal cord disease' were cross-indexed with 'employment', 'return to work', 'occupation' or 'vocational'.

RESULTS

Out of approximately 270 hits, 110 references were used, plus 13 more found elsewhere. Among individuals with SCI working at the time of injury 21 - 67% returned to work after injury. RTW was higher in persons injured at a younger age, had less severe injuries and higher functional independence. Employment rate improved with time after SCI. Persons with SCI employed ranged from 11.5% to 74%. Individuals who sustained SCI during childhood or adolescence had higher adult employment rates. Most common reported barriers to employment were problems with transportation, health and physical limitations, lack of work experience, education or training, physical or architectural barriers, discrimination by employers, and loss of benefits. Individuals with SCI discontinue working at younger age.

CONCLUSIONS

This review confirmed low employment rates after SCI. Future research should explore interventions aimed at helping people with SCI to obtain and sustain productive work.

Psychosocial aspects of traumatic spinal cord injury with onset during adolescence: a qualitative study

BACKGROUND/OBJECTIVE

Spinal cord injury (SCI) occurring during adolescence poses additional challenges because of the concurrent age-specific bio-psychosocial development. Full understanding of the psychosocial dimensions of rehabilitation requires exploration of the patient perspective. The objective of this study was to focus on psychosocial factors from the patient perspective in persons who had previously sustained a SCI during early and mid-adolescence (11-15 years of age).

METHODS

Twenty-four of the 28 persons who had sustained a SCI in Sweden from 1985 to 1996 participated in the study. Semistructured interviews were made an average of 10 years after injury. Narratives were analyzed qualitatively according to content analysis.

RESULTS

Parents and peers were found to have formed a crucial network. Parents frequently acted as advocates in interactions with health care providers, as supporters, and as containers of sorrow, frustration, and anger. Peers acted as promoters of activity and identity development. However, health care providers were perceived as not making sufficient use of this network.

CONCLUSIONS

Rehabilitation professionals might be encouraged to increase their knowledge of adolescence medicine to better meet the specific needs and demands of persons in this age group. It is further suggested that parents and peers be considered important partners in the joint rehabilitation effort.

Depression in adults who sustained spinal cord injuries as children or adolescents

STUDY DESIGN

Interview survey.

OBJECTIVE

To assess depression in adults with pediatric-onset spinal cord injuries (SCI) and to determine demographic and injury-related factors, and outcomes associated with depression, and to determine which other outcomes are associated with depression.

METHODS

Subjects were adults with pediatric-onset SCI who sustained SCI at age < or =18 years and were interviewed at age > or =24 years. This is part of a longitudinal study for which there were 864 eligible participants; 353 (41%) were interviewed. Of these, 232 were assessed for depression. A telephone interview was conducted that included a structured questionnaire and standardized measures (Functional Independence Measure, Craig Handicap Assessment and Reporting Technique, Short-Form 12 measure of health-related quality of life, Satisfaction with Life Scale, and Patient Health Questionnaire-9 to screen for depression).

RESULTS

Twenty-seven percent reported depressive symptoms ranging from mild to severe, and 7% reported having suicidal thoughts within the last 2 weeks, and 3% reported symptoms consistent with probable major depressive disorder (MDD). Depression was not significantly associated with any demographic factors but it was associated with incomplete injury (P = 0.013). Depression was also associated with many participation outcomes, health-related quality of life, life satisfaction, and medical complications.

CONCLUSIONS

Depression is a significant problem among adults with pediatric-onset SCI and is associated with poorer outcomes and lower quality of life. These findings should be addressed as clinicians prepare children and adolescents with SCI to transition to adulthood.

Addressing children's needs and evaluating rehabilitation outcome after spinal cord injury: the child needs assessment checklist and goal-planning program

BACKGROUND/OBJECTIVE

Spinal cord injury (SCI) is a devastating event with lasting implications for children and families. The rehabilitation of children and adolescents with SCI must be developmentally based, and goal-planning programs must respond to their changing needs as they grow. The Child Needs Assessment Checklist (ChNAC) and goal-planning program provides a developmentally sensitive way to assess and address young people's needs within the context of their family and community. This preliminary study investigated the utility of the ChNAC in planning rehabilitation goals and evaluating outcomes for young people.

METHODS

A retrospective review of scores on the ChNAC was conducted to assess the effectiveness of the goal-planning program in addressing pediatric patients' rehabilitation needs. The sample comprised 33 young people for whom both baseline and outcome ChNACs had been completed.

RESULTS

Comparison of goals achieved on baseline and outcome ChNACs by median percentage score showed improvements in 9 of 10 areas. Differences in scores were compared across demographic groups.

CONCLUSIONS

The ChNAC is a practical tool for planning young people's rehabilitation after SCI and assessing rehabilitation outcome. This study is a preliminary demonstration of the pediatric goal-planning program's effectiveness in achieving positive rehabilitation outcomes. Future research should replicate these results with larger samples and include detailed studies of the ChNAC's reliability and validity.

Impact of spinal cord dysfunction and obesity on the health-related quality of life of children and adolescents

OBJECTIVES

The objectives of this study were: (1) to compare the health-related quality of life (HRQOL) of children and adolescents with mobility impairments due to spinal cord injury (SCI) and spina bifida (SB) to the HRQOL of children and adolescent controls without mobility impairments (CTRL); and (2) to examine the impact of of obesity on the HRQOL of these subjects.

METHODS

The Pediatric Quality of Life Inventory (PedsQL) was administered to 42 SB, 71 SCI and 60 able-bodied subjects who were 8-20 years of age. Subjects were categorized as obese if their BMI exceeded the 95th percentile for age. Twenty-one CTRL, 26 SB and 26 SCI subjects were obese.

RESULTS

The SCI and SB subjects had significantly lower subscores than the control subjects on the physical (p < 0.001), emotional (p < .01), social (p < .001), and school (p < .001) domains of the PedsQL. The obese (CTRL) group had lower subscores on the physical (p < 0.001), social (p < 0.001), and psychosocial (p < 0.001) domains of the PedsQL as compared to the non-obese CTRL group, while there were no significant differences in subscores from the emotional and school domains. In contrast to the subjects without mobility impairment, there were no significant differences between the sub-scores of the obese and non-obese subjects with spinal cord dysfunction secondary to SCI or SB. The mean total PedsQL score of the non-obese control group (87.7 +/- 2.1) was significantly higher than the obese control group (75.2 +/- 3.4, p < 0.02), which in turn was significantly higher than the SCI group (63.7 +/- 2.2, p < 0.02), and the SB group (63.0 +/- 2.2, p < 0.02).

CONCLUSION

Patients with SCI and SB have significantly lower HRQOL than children and adolescents without mobility impairments. Whereas obesity significantly reduces the quality of life scores of adolescents without mobility impairments, it has no significant incremental effect on subjects with SCI or SB.