Functional improvement after pediatric spinal cord injury

Evaluation of Clinical Characteristics and Comorbid Conditions in Pediatric Traumatic Spinal Cord Injury Patients

Objective This study aimed to examine the demographic features and the most common comorbid conditions of pediatric traumatic spinal cord injury (SCI) patients who were admitted to Ankara Physical Therapy and Rehabilitation Training and Research Hospital's inpatient rehabilitation program. Materials and methods The demographic features, clinical features and cormorbid conditions of 147 pediatric traumatic SCI patients (age of injury 17 and under) who received an inpatient rehabilitation program in the hospital between 2009-2017 were retrospectively examined. Patients were divided into three groups according to the lesion location (cervical, thoracic, and lumbar); and into two groups according to the age of completing the development of osteoligamentous structures in the vertebral column (group 1: ≤ 10 years and group 2: >10 years), and the evaluated data were compared. Results 73.5% of the patients were male, the average age of injury was 13.60 ± 4.19 years, and the average duration of the disease was 11.17 ± 20.80 months. The most common etiological reason was falls from height (34.7%), and the most common level of injury was the thoracic region (49%). The most common comorbid conditions after SCI were found to be neurogenic bladder (91.2%), spasticity (41.54%), and neuropathic pain (29.3%). It was determined that neurogenic bladder was seen less in the lumbar region (p<0.001). Urinary tract infection was found more in the cervical group (p=0.004). In Group 1 (0-10 years), the median disease duration was longer, and the rate of thoracic region injury and complete injury was higher (p<0.05); in Group 2 (11-17 years), the rate of having stabilization operation after the injury was significantly higher (p<0.001). Conclusion It is crucial to prevent the etiological reasons in pediatric traumatic SCI patients, to treat the arising comorbid conditions in the early period, to take protective measures, and to follow up the patients regularly when necessary.

Children's outcomes in road traffic accidents: challenges for personal injury assessment

Children represent a specific group of road traffic accident (RTA) victims. Performing a personal injury assessment (PIA) on a child presents a significant challenge, especially when assessing permanent disabilities and needs. However, medico-legal recommendations for PIA in such cases are lacking. The main objective of this study was to analyse the differences between children and a young- and middle-aged adult population of RTA victims to contribute to the development of relevant guidelines. Secondary objectives were to identify and characterize specifics of children's posttraumatic damages regarding: (i) temporary and permanent outcomes; and (ii) medico-legal damage parameters in the Portuguese context. We performed a retrospective study of RTA victims by comparing two groups (n = 114 each) matched for acute injury severity (SD = 0.01): G1 (children) and G2 (young- and middle-aged adults). Logistic regression was used to estimate the odds ratios. G1 presented a greater chance of evolving without or with less severe body, functional and situational outcomes (three-dimensional assessment methodology), and with lower permanent functional disability values than G2. Our findings suggest that childhood trauma generally has a better prognosis than trauma in young- and middle-aged adults. This study generated evidence on the subject and highlighted the most significant difficulties encountered by medico-legal experts when performing PIA in children.

Key points

This retrospective study of PIA in child victims of RTA in Portugal considered outcomes in victims' real-life situations.Several significant differences between children and young- and middle-aged adults were observed.Children's cases presented better results in terms of the severity of body, functional and situational outcomes, and permanent damage parameters.The average time between the RTA and final PIA date and the consolidation time were longer for children because of the need to wait for the Children's next growth phase or final pubertal period (as applicable), which increased the time for PIA conclusion.There were several difficulties in the medical-legal evaluation of children's cases, which was a complex process because the trauma affected them in their growth phase.

Inpatient Rehabilitation After Pediatric and Adolescent Trauma: Outcomes and Discharge Needs

INTRODUCTION

Traumatic injury is the leading cause of pediatric mortality and morbidity in the United States. Pediatric trauma survivors requiring inpatient rehabilitation (IPR) require coordinated, multispecialty follow-up. Knowledge of the nature and level of disability is necessary for planning this continued care that is specific to the needs of pediatric trauma patients. This study aims to describe the outcomes of pediatric and adolescent trauma patients using measures of functional progression.

MATERIALS AND METHODS

A retrospective review of trauma patients aged ≤18 y admitted to IPR between January 2018 and December 2020 at the only certified pediatric rehabilitation center in the region was performed.

RESULTS

Ninety five children and adolescents were admitted to IPR after traumatic injury with diagnoses of multitrauma (MT, N = 18), traumatic brain injury (TBI, N = 59), and spinal cord injury (SCI, N = 18). School aged children returned to school at high rates for all injury types (MT: 86.7%, TBI: 97.4%, SCI: 93.8%, P = ns). All groups had similar hospital and rehabilitation length of stay, and most patients required a durable medical equipment at discharge (79%). Using pediatric functional independence measure scoring progression from admission to discharge from IPR, SCI patients made significant improvement in bladder function and the least improvement in stair function. Patients sustaining a TBI made significant improvement in memory and comprehension tasks.

CONCLUSIONS

Pediatric and adolescent trauma patients admitted to IPR had a positive progression during their therapy but required variable ongoing care depending on the mechanism of injury. Excellent rates of returning to school were seen across the three injury types.

Use of the Physical Abilities and Mobility Scale (PAMS) in Children Receiving Inpatient Rehabilitation for Spinal Cord Related Paralysis

OBJECTIVES

To investigate the performance of the Physical Abilities and Mobility Scale (PAMS) in children receiving inpatient rehabilitation for paralysis related to spinal cord disease and injury (SCD/SCI).

METHODS

Participants were 146 children with paralysis related to SCD/SCI, aged 2-21, admitted between January 2010 and 2017 for inpatient rehabilitation at a single free-standing academically affiliated pediatric rehabilitation hospital. Retrospective chart review was performed to obtain admission and discharge scores on the PAMS and the functional independence measure for children (WeeFIM®), collected as part of clinical care. Internal consistency was evaluated using Cronbach's alpha. Inter-rater reliability was evaluated through overall agreement, Pearson correlations, and intraclass correlations. Construct validity was examined through exploratory factor analysis. Criterion validity was explored through correlations of PAMS overall and item scores with WeeFIM® total and subscale scores. Sensitivity to change was tested using paired t-tests examining differences between admission and discharge scores for each item and for the total score on the PAMS.

RESULTS

Internal consistency and inter-rater reliability were high (0.94 at admission and 0.95 at discharge). Total PAMS scores are highly correlated with total WeeFIM®, mobility, self-care, and cognitive subscores at admission and discharge. Correlations with the WeeFIM® ranged from low (cognitive) to strong (mobility). Total PAMS score and all individual items increased significantly between admission and discharge.

CONCLUSIONS

The PAMS is a useful measure capturing incremental and granular functional motor skills changes occurring during inpatient rehabilitation for children with spinal cord-related paralysis.

Indicators of Quality of Care in Individuals With Traumatic Spinal Cord Injury: A Scoping Review

STUDY DESIGN

Scoping review.

OBJECTIVES

To identify a practical and reproducible approach to organize Quality of Care Indicators (QoCI) in individuals with traumatic spinal cord injury (TSCI).

METHODS

A comprehensive literature review was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL) (Date: May 2018), MEDLINE (1946 to May 2018), and EMBASE (1974 to May 2018). Two independent reviewers screened 6092 records and included 262 full texts, among which 60 studies were included for qualitative analysis. We included studies, with no language restriction, containing at least 1 quality of care indicator for individuals with traumatic spinal cord injury. Each potential indicator was evaluated in an online, focused group discussion to define its categorization (healthcare system structure, medical process, and individuals with Traumatic Spinal Cord Injury related outcomes), definition, survey options, and scale.

RESULTS

A total of 87 indicators were identified from 60 studies screened using our eligibility criteria. We defined each indicator. Out of 87 indicators, 37 appraised the healthcare system structure, 30 evaluated medical processes, and 20 included individuals with TSCI related outcomes. The healthcare system structure included the impact of the cost of hospitalization and rehabilitation, as well as staff and patient perception of treatment. The medical processes included targeting physical activities for improvement of health-related outcomes and complications. Changes in motor score, functional independence, and readmission rates were reported as individuals with TSCI-related outcomes indicators.

CONCLUSION

Indicators of quality of care in the management of individuals with TSCI are important for health policy strategists to standardize healthcare assessment, for clinicians to improve care, and for data collection efforts including registries.

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.

Improvements in Function Following Inpatient Activity-Based Therapy for Children With Acute Flaccid Myelitis

BACKGROUND

Acute flaccid myelitis (AFM) is an illness defined by rapid onset of flaccid paralysis in one or more limbs or bulbar muscles, with MRI findings of predominantly spinal cord gray matter abnormalities spanning one or more spinal segments following a viral illness. Individuals with AFM may require rehabilitation to promote recovery. Activity-based restorative therapy (ABRT) has previously been shown to result in positive outcomes in children with neurologic deficits related to AFM.

OBJECTIVES

This study examined functional changes in a group of children with AFM who participated in ABRT in an inpatient setting.

METHODS

Retrospective chart review of children with AFM admitted to a single inpatient rehabilitation unit from 2014 to 2018. Children were assessed using the Functional Independence Measure for Children (WeeFIM), Manual Muscle Testing (MMT), Spinal Cord Independence Measure (SCIM), and the Physical Abilities and Mobility Scale (PAMS) as part of routine clinical care; the Modified Rankin Scale for Neurologic Disability was completed retrospectively.

RESULTS

Children showed significant improvements across all outcome measures, with effect sizes ranging from moderate to large. Significant change was also seen across all muscle groups on MMT, with effect sizes ranging from small to large. Consistent with previous reports, children demonstrated better function in distal than proximal muscle groups at both admission and discharge.

CONCLUSION

Children with AFM who participated in ABRT increased muscle strength and made functional gains across all outcome measures. These results support the utility of rehabilitation in the long-term care of children with AFM and residual neurologic deficit.

Association Between Pediatric Inpatient Rehabilitation Services and Children's Functional Outcomes: King Fahad Medical City Experience

Background:

Disability may affect children’s performance of functional activities. This may translate to difficulties in returning to home and/or school. It has been documented that intensive rehabilitation programs for children with disabilities lead to an improvement in their functional abilities. Wee-FIM is a valid and reliable outcome measure that is used commonly with children undergoing rehabilitation.

Objectives:

To study changes in the functional status of children admitted to a specialized pediatric inpatient rehabilitation unit.

Design:

A retrospective cohort study.

Setting:

King Fahad Medical City—Rehabilitation Hospital, Riyadh, Saudi Arabia.

Methods:

Investigators reviewed records of children admitted to a pediatric rehabilitation unit between January 1, 2012, and December 31, 2017. The outcome measures used were rehabilitation length of stay (LOS), Wee-FIM gain, and Wee-FIM efficiency.

Results:

The total number of records included in this study was 361 records. Sixty percent of the children were boys. The mean age was 8.7 ± 3.8 years (range, 3-17 years). Children with cerebral palsy accounted for 45.2% of the children. The mean LOS was 43 days. Children with brain tumors had the shortest LOS compared with children with other diagnoses. Mean (SD) Wee-FIM efficiency was 0.58 (±0.6). Highest Wee-FIM efficiency was observed in children with brain tumors. Average Wee-FIM gain was 20 (±15). The highest functional gain was 27 in children with brain tumors while the lowest was 16 in children with cerebral palsy.

Conclusions:

Intensive inpatient rehabilitation program is associated with improvement in functional performance in children with a variety of impairments and disabilities.

Traumatic spinal cord injuries: A retrospective cohort study of children seen in Western Australia between 1996 and 2016

PURPOSE

To describe the medical complexity of traumatic spinal cord injury (TSCI) in paediatric patients in Western Australia (WA). Secondly, to determine if Princess Margaret Hospital (PMH) for Children (the tertiary paediatric centre in WA where all TSCI patients are managed) is meeting the requirements of the Australasian Rehabilitation Outcomes Centre (AROC) paediatric rehabilitation minimum data set gathered on each patient.

METHODS

Retrospective cohort study of patients seen at PMH between 1996-2016. The AROC minimum dataset information data were gathered on each patient. Functional status and rehabilitation outcomes were assessed using Functional Independence Measure for Children (weeFIM), Canadian Occupational Performance Measure (COPM), and Goal Attainment Scaling (GAS). Patient complexity was captured by documenting the specialty teams involved, the number of readmissions, and the International Statistical Classification of Disease and Related Health Problems Z codes.

RESULTS

Data from 19 patients (13 males, age range 6 months-15 years; 6 females, age range 4 years-13 years) were available. There were 10 cervical TSCIs with a median length of stay of 213 days and 9 thoracic TSCIs with a median length of stay of 49 days. Patients had between zero and six comorbidities prior to their TSCI.

CONCLUSIONS

Children with medical complexity are responsive to rehabilitation but have a high burden of care, requiring multiple-specialty care and hospital re-admissions. AROC has set a minimum data set recommendation for the collection and examination of patient data. PMH meets the AROC guidelines for patient data collection and descriptive analyses.

Pediatric intramedullary spinal cord tumor outcomes using the WeeFIM scale

PURPOSE

The Functional Independence Measure for children (WeeFIM) is a user-friendly functional outcomes tool that has been validated across other traditional functional scales. Historically, the significant neurologic and functional deficits of intramedullary spinal cord tumors (IMSCTs) have been monitored by coarse or overbearing functional outcomes tools that make it difficult to measure the slow improvement/decline seen in these patients. This study is the first to report WeeFIM outcomes on a series of IMSCTs with emphasis on an aggressive surgical strategy.

METHODS

A retrospective review from 2005 to 2014 was performed for nine patients who underwent resective surgery for intramedullary spinal cord tumors with intraoperative ultrasound and neurophysiologic monitoring. WeeFIM scales were assessed at admission and discharge to evaluate changes in severity of disability and need for assistance.

RESULTS

At the time of this submission, 7/9 patients are alive. The mean WeeFIM improvement was 27 points (8-50 points) with a mean WeeFIM efficiency of 2.0 points/day.

CONCLUSIONS

The WeeFIM scale is an appropriate and useful scale for measuring postoperative improvements in patients with IMSCTs undergoing aggressive resective surgery. Attention to intraoperative spinal cord monitoring and prevention of spinal column instability may prevent morbidity related to surgery, and functional outcomes do not appear to be compromised by an aggressive surgical approach.

A Novel Protocol for Contact Isolation for Multidrug-Resistant Organisms in Children on Inpatient Rehabilitation and Effects on Functional Outcomes: A Noninferiority Study

BACKGROUND

The incidence of contact isolation for multidrug-resistant organisms is increasing in acute hospitals and inpatient rehabilitation units alike. There is limited evidence on the effect of contact isolation on functional outcomes during inpatient rehabilitation.

OBJECTIVE

To determine whether the use of a modified contact isolation protocol (MCI) resulted in noninferior functional outcomes compared with children without contact isolation (NCI) on inpatient rehabilitation.

DESIGN

This is a retrospective noninferiority study.

SETTING

One academically affiliated pediatric inpatient rehabilitation unit located in a children's hospital.

PATIENTS

All children with any diagnosis admitted to inpatient rehabilitation from January 1, 2007, to December 31, 2014.

METHODS OR INTERVENTIONS

We compared functional outcomes for 2 groups of children.

MAIN OUTCOME MEASUREMENTS

Primary outcome measures included the Functional Independence Measure for Children (WeeFIM) efficiency and the change in the Developmental Functional Quotient (DFQ) for the WeeFIM. Noninferiority margins of 0.63 for the WeeFIM efficiency and 0.092 for the change in DFQ for the WeeFIM were used.

RESULTS

There were a total of 949 patients of whom 899 were NCI, 48 MCI, and 2 excluded due to missing information. Patients with MCI had functional outcomes that were noninferior to those with NCI including the WeeFIM efficiency (mean difference 0.002, 95% CI -0.38 to 0.404) and the change in DFQ for the WeeFIM (mean difference -0.05, 95% CI -0.058 to 0.003).

CONCLUSIONS

The modified contact isolation protocol, having resulted in noninferior functional outcomes in inpatient rehabilitation may provide adequate contact isolation while allowing for noninferior functional outcomes. This may be a guide in the face of an ever-increasing need for contact isolation.

LEVEL OF EVIDENCE

III.

Recommendations for the National Institute for Neurologic Disorders and Stroke spinal cord injury common data elements for children and youth with SCI

STUDY DESIGN

In 2014, the adult spinal cord injury (SCI) common data element (CDE) recommendations were made available. This project was a review of the adult SCI CDE for relevance to children and youth with SCI.

OBJECTIVES

The objective of this study was to review the National Institute of Neurologic Disorders and Stroke (NINDS) adult SCI CDEs for relevance to children and youth with SCI.

SETTING

International.

METHODS

The pediatric working group consisted of international members with varied fields of expertise related to pediatric SCI. The group convened biweekly meetings for 6 months in 2015. All of the adult SCI CDEs were reviewed, evaluated and modified/created for four age groups: 0-5 years, 6-12 years, 13-15 years and 16-18 years. Whenever possible, results of published research studies were used to guide recommendations. In the absence of empirical support, grey literature and international content expert consensus were garnered. Existing pediatric NINDS CDEs and new CDEs were developed in areas where adult recommendations were not appropriate. After internal working group review of domain recommendations, these pediatric CDEs were vetted during a public review from November through December 2015.

RESULTS

Version 1.0 of the pediatric SCI CDEs was posted in February 2016.

CONCLUSION

The pediatric SCI CDEs are incorporated directly into the NINDS SCI CDE sets and can be found at https://commondataelements.ninds.nih.gov.

Measuring activity limitation outcomes in youth with spinal cord injury

STUDY DESIGN

A cross-sectional study.

OBJECTIVES

The Pediatric Spinal Cord Injury Activity Measure (PEDI-SCI AM), which includes calibrated item banks (child and parent versions) for general mobility, daily routines, wheeled mobility and ambulation, can be administered using computerized adaptive tests (CATs) or short forms (SFs). The study objectives are as follows: (1) to examine the psychometric properties of the PEDI-SCI AM item banks and 10-item CATs; and (2) to develop and evaluate the psychometric properties of PEDI-SCI AM SFs.

SETTING

US Shriners Hospitals for Children (California, Illinois and Pennsylvania).

METHODS

Calibration data from a convenience sample of 381 children and adolescents with SCI and 322 parents or caregivers were used to examine PEDI-SCI AM item banks, 10-item CATs and SF scores. We calculated group reliability, internal consistency (Cronbach's alpha) and interclass coefficients (ICCs) to assess agreement between 10-item CATs, SFs and item banks. The percent of the sample with highest (ceiling) and lowest (floor) scores was also determined. An expert panel selected items for 14 SFs.

RESULTS

PEDI-SCI item banks, 10-item CATs and SFs demonstrate acceptable group reliability (0.73-0.96) and internal consistency (0.77-0.98). ICC values show strong agreement with item banks for 10-item CATs (0.72-0.99) and SFs. Floor effects are minimal (<15%). Ceiling effects are minimal for children with tetraplegia but high in children with paraplegia for general mobility (13.41-26.05%) and daily activities (12.99-32.71%).

CONCLUSIONS

The PEDI-SCI AM exhibited strong psychometric properties for children with tetraplegia. Replenishment of the general mobility and daily routine item banks is needed to reduce ceiling effects noted for youth with paraplegia.

Early rehabilitation improves neurofunctional outcome after surgery in children with spinal tumors

To investigate the effect of early rehabilitation on neurofunctional outcome after surgery in children with spinal tumors, this study reviewed the medical charts and radiographic records of 70 pediatric patients (1–17 years old) who received spinal tumor surgical removal. The peddiatric patients received rahabilitation treatment at 4 (range, 2–7) days after surgery for 10 (range, 7–23) days. Results from the Modified McCormick Scale, Functional Independence Measure for Children, American Spinal Injury Association Impairment Scale and Karnofsky Performance Status Scale demonstrated that the sensory function, motor function and activity of daily living of pediatric children who received early rehabilitation were significantly improved. Results also showed that tumor setting and level localization as well as patients's clinical symptoms have no influences on neurofunctional outcomes.

Validity of computer adaptive tests of daily routines for youth with spinal cord injury

OBJECTIVE

To evaluate the accuracy of computer adaptive tests (CATs) of daily routines for child- and parent-reported outcomes following pediatric spinal cord injury (SCI) and to evaluate the validity of the scales.

METHODS

One hundred ninety-six daily routine items were administered to 381 youths and 322 parents. Pearson correlations, intraclass correlation coefficients (ICC), and 95% confidence intervals (CI) were calculated to evaluate the accuracy of simulated 5-item, 10-item, and 15-item CATs against the full-item banks and to evaluate concurrent validity. Independent samples t tests and analysis of variance were used to evaluate the ability of the daily routine scales to discriminate between children with tetraplegia and paraplegia and among 5 motor groups.

RESULTS

ICC and 95% CI demonstrated that simulated 5-, 10-, and 15-item CATs accurately represented the full-item banks for both child- and parent-report scales. The daily routine scales demonstrated discriminative validity, except between 2 motor groups of children with paraplegia. Concurrent validity of the daily routine scales was demonstrated through significant relationships with the FIM scores.

CONCLUSION

Child- and parent-reported outcomes of daily routines can be obtained using CATs with the same relative precision of a full-item bank. Five-item, 10-item, and 15-item CATs have discriminative and concurrent validity.

Pediatric arrowshot injury to cervical spinal cord-sagittal cord transection with no neurological deficit and good outcome: case report and review of literature

BACKGROUND

Penetrating spinal cord injuries (PSCI) in cervical region are extremely rare in children. They mostly occur in a mechanism of a gunshot or a stab injury with the use of sharp objects. Gunshot injuries are usually fatal or end up with tetraplegia. Stab wounds may be less severe and result in partial neurological syndrome. In the management of PSCI in children, reliable diagnostics and history of the patient are the most valuable for further decisions, which include early or delayed exploration either nonsurgical treatment. There exist no clear algorithm for antibiotic use in pediatric population--it depends on the site of an injury, presence of pathological secretion from the wound, and nature of the trauma. The use of steroids is controversial. The most common complications related to surgery include infections, edema, and hemorrhage. They may also be associated with the migration of small residual microtraumatizing agent. The literature lacks algorithms for management in children.

DISCUSSION

In this paper, an unusual case of almost total sagittal cervical cord transection is reported. The patient had no neurological symptoms and recovered with no complications. Diagnostic imaging on admission included X-ray and computed tomography. The patient underwent early surgical intervention with removal of foreign body from the cord and subsequent dural suturing. In the paper, the role of detailed history taking, adequate imaging, and drugs administration is discussed. The choice of distinct strategies is analyzed, and a revised literature review is presented in order to unify the management algorithm for pediatric PSCI.

The SCIRehab project: treatment time spent in SCI rehabilitation. Inpatient treatment time across disciplines in spinal cord injury rehabilitation

BACKGROUND/OBJECTIVE

Length of stay (LOS) for rehabilitation treatment after spinal cord injury (SCI) has been documented extensively. However, there is almost no published research on the nature, extent, or intensity of the various treatments patients receive during their stay. This study aims at providing such information on a large sample of patients treated by specialty rehabilitation inpatient programs.

METHODS

Six hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient encounter. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patient's stay and total minutes of treatment per week were calculated. Ordinary least squares stepwise regression models were used to identify patient and injury characteristics associated with time spent in rehabilitation treatment overall and within each discipline.

RESULTS

Average LOS was 55 days (standard deviation 37), during which 180 (106) hours of treatment were received, or 24 (5) hours per week. Extensive variation was found in the amount of treatment received, between and within neurologic groups. Total hours of treatment provided throughout a patient's stay were primarily determined by LOS, which in turn was primarily predicted by medical acuity. Variation in minutes per week of treatment delivered by individual disciplines was predicted poorly by patient and injury characteristics.

CONCLUSIONS

Variations between and within SCI rehabilitation patient groups in LOS, minutes of treatment per week overall, and for each rehabilitation discipline are large. Variation in treatment intensity was not well explained by patient and injury characteristics. In accordance with practice-based evidence methodology, the next step in the SCIRehab study will be to determine which treatment interventions are related with positive outcomes (at 1 year post injury), after controlling for patient and injury differences.

Epidemiology and Management of Injuries to the Spinal Cord and Column in Pediatric Multiple-Trauma Patients

Injuries to the spinal column and cord in children are a rare condition. Epidemiological data could help to establish an evidence-based assessment and therapy of these patients. We present a retrospective chart analysis of children with spinal injuries who were admitted to the emergency room. The patients were analyzed regarding age, mechanism, and distribution of their injuries to all spinal regions and treatment strategies. Thirty-five children met the inclusion criteria with severe spinal injuries (Abbreviated Injury Scale [AIS] for Region 6 [spine]; AIS region 6) in a period from January 2003 to December 2009. The incidence was extremely low in younger children, with increasing numbers during adolescence. Neurological deficit without fracture accounted for almost 25% of all patients. The majority of patients were treated conservatively; operative treatment was performed in 25% of patients with unstable fractures, particularly in adolescents. Treatment strategies differ according to the type and degree of injury, age, and level of spine maturation.

Functional recovery in children and adolescents with spinal cord injury

PURPOSE

To examine functional recovery in mobility and self-care measured using the Pediatric Evaluation of Disability Inventory (PEDI) in children with spinal cord injury (SCI) during an inpatient rehabilitation stay and to identify how demographic and clinical variables relate to functional recovery.

METHODS

PEDI scores were collected through retrospective chart review for 32 children and adolescents with SCI (mean age, 10.6 +/- 6.2 years; range, 1-19 years) admitted to an inpatient physical rehabilitation program between 1995 and 2007.

RESULTS

Children with SCI showed significantly improved functional skill recovery and reduced caregiver assistance for the PEDI mobility and self-care domains after rehabilitation. Item analyses suggested more recovery in mobility than in self-care skills. Children with incomplete injury gained more independence in self-care than those with complete injury.

CONCLUSIONS

Children with SCI showed improved functional skills and reduced need for caregiver assistance as measured by the PEDI during inpatient rehabilitation.

Development of items designed to evaluate activity performance and participation in children and adolescents with spinal cord injury

Background/Objective. Outcomes-based data, whether used clinically or for research, are difficult to collect in the pediatric spinal cord injury (SCI) population due to a lack of appropriate assessment measures. The purpose of this paper is twofold: to describe the process by which two item pools were developed to evaluate activity performance and participation among children with SCI and to introduce the resultant items specific to pediatric SCI. Methods. The process of item development, including construct development, review of related assessment tools, chart review, item writing and refinement using focus groups, cognitive interviews, and further refinement, was used to create the items pools for activity and participation for children and adolescents with SCI. Results. A total of 347 items were written for the activity performance construct and 61 items were written for the participation construct. Several domains were established within each construct and items were written for both child and parent respondents. Conclusion. The process of detailed item development is the first step in the process of developing an outcomes instrument for children and adolescents with SCI to assess activity performance and participation. The items are representative of pediatric SCI because they address areas specific to children and adolescents with SCI such as wheeled mobility, upper extremity function with adaptive equipment, role performance, and socialization. After testing these items in calibration studies, we will determine if these items can be developed into effective computer-adaptive testing applications.

Children's reports of activity and participation after sustaining a spinal cord injury: a cognitive interviewing study

OBJECTIVE

To evaluate the readability, comprehension and response processes of test items designed to measure activity performance and participation by children with spinal cord injury (SCI).

METHODS

Eleven parents and 33 children participated. Descriptive statistics were used to calculate frequency of problems based on age, grade, domain and response scale. Agreement was evaluated by weighted kappa coefficient values.

RESULTS

Most (54%) of the problems were due to reading/comprehension, with the majority by children 8 years of age or younger (56%) who had not completed 2nd grade (51%). Agreement between child-parent reports ranged from poor-good, with strongest agreement for mobility items and weak agreement for chores, self-care and participation.

CONCLUSION

Children with SCI 8 years of age and older who have competed 2nd grade are able to read, understand and respond to items associated with activity performance and participation.

New approach to study the contents and outcomes of spinal cord injury rehabilitation: the SCIRehab Project

BACKGROUND/OBJECTIVE

Limited research evidence is available to show the effectiveness of the many specific interventions provided in spinal cord injury (SCI) rehabilitation; what is available typically focuses on effects of the full rehabilitation package but not specific therapy interventions, medical procedures, patient education, or counseling. Given the problems of conducting randomized controlled trials (RCTs) in rehabilitation, practice-based evidence (PBE) research has been suggested as an alternative methodology for identifying which rehabilitation interventions are associated most strongly with positive outcomes, after controlling for patient differences. Using the PBE research methodology, the SCIRehab project attempts to "open the black box" of acute SCI rehabilitation, provide detailed information on treatments delivered by all rehabilitation disciplines, and contribute to outcomes-based guidelines for clinical decision-making.

METHODS

The SCIRehab project includes 1,500 patients with acute SCI, consecutively admitted to 1 of 6 US inpatient rehabilitation facilities. Details of the rehabilitation process are captured by clinicians from multiple disciplines documenting their interventions in handheld personal digital assistants after sessions with their patients. Outcome data are abstracted from medical records (clinical outcomes data) and obtained from patient interviews at 6 and 12 months after injury. Extensive patient, injury, and other treatment characteristics are abstracted from medical records. SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team.

RESULTS

SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team. These findings are presented in a series of 9 articles.

CONCLUSIONS

To date, SCIRehab's major contribution is a system for categorizing specific contributions of each discipline and a technology for documenting that detail. After data collection is complete, future manuscripts will relate those process elements to outcomes. The SCIRehab Project is an important step toward establishing outcomes-based guidelines for SCI rehabilitation.

Self-report measures of physical function for children with spinal cord injury: a review of current tools and an option for the future

OBJECTIVE

The purpose of this article is to provide paediatric rehabilitation providers with a review of self-report physical function outcome measures that have been used for children with spinal cord injury (SCI).

REVIEW PROCESS

A literature review was conducted to identify self-report physical function measures for children with SCI. Further searching of reference lists and textbooks was also completed.

OUTCOMES

Eight measures were identified, but limitations exist in these current tools. There are few reports of psychometrics, in addition to a lack of accommodation for wheelchair use, limited item content for supported ambulation and minimal variation in content for a wide age-range.

CONCLUSION

A comprehensive yet practical self-report measure applicable for all ages with items suitable for a child with a complete or incomplete injury is needed. The best means to achieve effective and efficient outcome monitoring may be computerized adaptive testing.

Progression of spinal cord atrophy by traumatic or inflammatory myelopathy in the pediatric patients: case series

STUDY DESIGN

Case series.

OBJECTIVE

To present spinal cord atrophy in pediatric patients who had spinal cord injury developed after trauma or acute transverse myelitis, and had no motor recovery later.

SETTING

Department of Rehabilitation Medicine, Tertiary National University Children's Hospital, Seoul, Korea.

METHODS

Case series.

RESULTS

Two pediatric patients with paraplegia due to acute transverse myelitis and one pediatric patient with paraplegia due to traumatic myelopathy were included in this case series. Their initial MRI (magnetic resonance imaging) findings were spinal cord swelling and high signal intensity in T2-weighted image. After several months, they had no motor recovery and showed no change of neurological level, though they underwent steroid and physical therapy. A follow-up MRI revealed spinal cord atrophy.

CONCLUSION

If a pediatric patient with traumatic or inflammatory spinal cord injury does not show motor recovery after several months, spinal cord atrophy must be considered.

Traumatic brain injury: a comparison of inpatient functional outcomes between children and adults

OBJECTIVES

To examine age-related differences in functional outcomes following traumatic brain injury. PARTICIPANTS AND PROCEDURE: Seventy-six patients admitted to a pediatric acute rehabilitation hospital were compared with 2548 adult patients in the National Institute on Disability and Rehabilitation Research-funded traumatic brain injury model systems national database.

MAIN OUTCOME MEASURES

Functional Independence Measure totals during inpatient rehabilitation.

RESULTS

Increasing age was significantly associated with improved outcome in children and with poorer outcome in adults.

CONCLUSION

The relationship between age and functional outcome is different within different age groups (pediatric vs adult), and the effect of moderating variables differs by age group.

Motor scores on the functional independence measure after pediatric spinal cord injury

STUDY DESIGN

Retrospective descriptive analysis.

OBJECTIVES

The purpose of this study was to report the functional ability of children with spinal cord injury (SCI) as recorded on motor items of the functional independence measure (FIM) and to examine the factors associated with FIM motor admission and post-discharge gain scores.

METHODS

Scores on FIM motor items were analyzed from 941 children (age range: 0-21 years; mean: 13 years 4 months; s.d.: 4 years 8 months) admitted in acute-to-chronic time periods post-SCI to Shriners Hospitals for Children (USA). FIM motor scores at admission and gains at discharge were examined along with neurological level, completeness of injury, age, etiology of injury, and length of time between injury and admission and admission and discharge.

RESULTS

The FIM motor scores at admission were negatively correlated with age, neurological level and completeness of injury. Gain in FIM motor scores was significant across neurological levels, and was associated with lower admission FIM motor scores, lower neurological level, incomplete injury, traumatic injury and less time between injury and admission.

CONCLUSIONS

The motor function of children after pediatric SCI depends on neurological level and completeness of injury, among other factors. FIM motor scores can improve with intervention even several years after the injury.

Locomotor training restores walking in a nonambulatory child with chronic, severe, incomplete cervical spinal cord injury

BACKGROUND AND PURPOSE

Locomotor training (LT) enhances walking in adult experimental animals and humans with mild-to-moderate spinal cord injuries (SCIs). The animal literature suggests that the effects of LT may be greater on an immature nervous system than on a mature nervous system. The purpose of this study was to evaluate the effects of LT in a child with chronic, incomplete SCI.

SUBJECT

The subject was a nonambulatory 4 1/2-year-old boy with an American Spinal Injury Association Impairment Scale (AIS) C Lower Extremity Motor Score (LEMS) of 4/50 who was deemed permanently wheelchair-dependent and was enrolled in an LT program 16 months after a severe cervical SCI.

METHODS

A pretest-posttest design was used in the study. Over 16 weeks, the child received 76 LT sessions using both treadmill and over-ground settings in which graded sensory cues were provided. The outcome measures were ASIA Impairment Scale score, gait speed, walking independence, and number of steps.

RESULT

One month into LT, voluntary stepping began, and the child progressed from having no ability to use his legs to community ambulation with a rolling walker. By the end of LT, his walking independence score had increased from 0 to 13/20, despite no change in LEMS. The child's final self-selected gait speed was 0.29 m/s, with an average of 2,488 community-based steps per day and a maximum speed of 0.48 m/s. He then attended kindergarten using a walker full-time.

DISCUSSION AND CONCLUSION

A simple, context-dependent stepping pattern sufficient for community ambulation was recovered in the absence of substantial voluntary isolated lower-extremity movement in a child with chronic, severe SCI. These novel data suggest that some children with severe, incomplete SCI may recover community ambulation after undergoing LT and that the LEMS cannot identify this subpopulation.

Measuring children's health-related quality of life after trauma

Consideration of children's health-related quality of life (HRQOL) after injury is a critical aspect of outcome in assessing the effectiveness of trauma care. Numerous instruments are available today for measuring the HRQOL of injured children. HRQOL instruments reflect the subjective perspective of the impact an injury or disease has on a child's physical, emotional, and social well being. Most studies to date have examined children's HRQOL during the first year postinjury, relatively little is known about children's long-term HRQOL after trauma. Most trauma outcome studies have included children with heterogeneous injuries so the impact of specific injuries on HRQOL outcomes has not been well established. The majority of outcome studies have focused on injured children who have been hospitalized, however the research should be extended to the emergency department because a large proportion of injured children are treated and released from there. In addition to documenting recovery, investigators should use HRQOL instruments to evaluate the quality of care we offer injured children and their families. Rigorously conducted HRQOL assessment will provide valuable information that we can use to successfully optimize children's recovery after trauma.

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.

Locomotor training within an inpatient rehabilitation program after pediatric incomplete spinal cord injury

BACKGROUND AND PURPOSE

The outcomes of intense locomotor training after incomplete spinal cord injury (SCI) have been described in adults with acute and chronic injuries and with various levels of ambulatory function. This case report describes a comprehensive inpatient rehabilitation program with a locomotor training component in a child with a severe incomplete SCI.

CASE DESCRIPTION

A 5-year-old girl injured at C4 participated in locomotor training for 5 months during inpatient rehabilitation.

OUTCOMES

The patient's Functional Independence Measure for Children II (WeeFIM II) mobility score increased from 5/35 to 21/35. Her Walking Index for Spinal Cord Injury II (WISCI II) score improved from 0 to 12. The patient returned to walking in the community with assistive devices.

DISCUSSION

It is feasible to include an intense locomotor training program in the clinical rehabilitation setting for a child with a severe SCI, and the outcomes were consistent with results in adults. Further investigation with experimental designs and more participants will determine the extent to which this intervention benefits the pediatric population with SCI.

Assessing outcomes in paediatric trauma populations

INTRODUCTION

Assessing outcomes in the paediatric trauma population is important. Identifying suitable instruments can be problematic. This article highlights the commonly used outcome measures for assessing functional status and health related quality of life in paediatric trauma patients. Child specific characteristics which impact upon instrument development and selection are reviewed.

METHODS

An electronic database search was conducted to identify suitable English language measures used for outcome assessment in paediatric trauma patients from 1966 to present.

RESULTS

Nine suitable instruments were identified, the child health questionnaire (CHQ), Glasgow outcome scale (GOS), paediatric overall performance category (POPC), PedsQL 4.0 generic core scales, paediatric evaluation of disability inventory (PEDI), functional independence measure (FIM), WeeFIM and an unnamed paediatric trauma specific measure [Gofin R, Hass T, Adler B, The development of disability scales for childhood and adolescent injuries. J Clin Epidemiol 1995;48:977-84]. Each instrument was found to have advantages and disadvantages for assessing outcomes in a paediatric trauma population.

CONCLUSION

The PedsQL 4.0 generic core scale could be feasible for administration as a routine outcome measure for paediatric trauma groups. For very young children an additional measure such as that proposed by Gofin et al. [Gofin R, Hass T, Adler B, The development of disability scales for childhood and adolescent injuries. J Clin Epidemiol 1995;48:977-84] may be indicated. Future use of these instruments in the paediatric population would benefit from further psychometric evaluation.

A prospective evaluation of the WeeFIM in patients with cerebral palsy undergoing orthopaedic surgery

PURPOSE

Although frequently used in pediatric rehabilitation settings, the WeeFIM has not been tested in surgical pediatric orthopaedic patients.

METHODS

The WeeFIM was administered to patients with surgical cerebral palsy at defined intervals preoperatively and at both 6 and 12 months postoperatively. The age-adjusted change scores from baseline to follow-up were tested both parametrically and nonparametrically.

RESULTS

Four hundred sixty-eight patients had baseline evaluations. There were 161 six-month follow-up assessments and 108 twelve-month follow-up assessments. The baseline WeeFIM was able to separate children with different patterns of cerebral palsy. Hemiplegic patients had higher scores than diplegic and tetraplegic patients. Overall age-adjusted scores were improved at both 6 (mean increase 2.0) and 12 months (mean increase 2.2). The instrument showed significant ceiling effects for diplegic and hemiplegic patients with lower or upper extremity surgery and limited responsiveness for lower extremity surgery in tetraplegic patients. Parametrically, it showed improvements in mobility for both rhizotomy and tetraplegic upper extremity surgery. Nonparametric tests were not significant for rhizotomy mobility improvement.

CONCLUSIONS

Although the WeeFIM adequately reflects the severity of neurological involvement in pediatric orthopaedic patients with cerebral palsy, it has a significant ceiling effect in diplegic and hemiplegic patients limiting responsiveness and lacks content validity for tetraplegic patients. The instrument may have some use in tetraplegic patients with upper extremity surgery and in rhizotomy patients. We recommend against its general use for orthopaedic surgery in patients with cerebral palsy lower extremity or spine surgery and in hemiplegic patients with upper extremity surgery.

Relationship between the clinical-neurophysiologic pattern, disability, and quality of life in adolescents with spina bifida

A number of studies have focused on quality of life in children with spina bifida, concentrating for the most part on younger children. We assessed health-related quality of life and disability in adolescents with spina bifida and correlated these with the clinical and neurophysiologic picture. Twelve consecutive spina bifida cases were evaluated through a multiperspective protocol by means of (1) clinical and neurophysiologic assessment, (2) a self-administered questionnaire for general health--Short Form-36 (SF-36)--and (3) standardized disability measurements (Functional Independence Measure, Barthel Index, Deambulation Index). Relationships between disability measurement, the adolescents' perspective, and conventional clinical and neurophysiologic assessment were evaluated. The Functional Independence Measure is strongly related to the clinical measurement of muscle strength (P < .03, r > .6). The Barthel Index and Deambulation Index are related to clinical measurement of muscle strength (P < .03, r > .6), as well as to electromyographic findings in the proximal muscles of inferior limbs (P < .05, r > .6). Although the function of lower limb muscles, especially the proximal muscles, is closely related to impairment of physical aspects of quality of life, it is only partially related to the mental aspects (P < .03, r > .6). The findings at clinical examination, especially proximal deficit of inferior limbs, were usually related to higher disability and lower physical aspects of quality of life. The multiperspective evaluation of adolescents with spina bifida shows a high correlation between conventional neurologic-neurophysiologic measurements and the adolescents' own perspective of their quality of life. Our data demonstrated that the conventional clinical and neurophysiologic measurements are useful not only because they provide a measure of lower limb impairment but also because they appear to be related to physical aspects of the adolescent's quality of life.

Spinal injuries in children

BACKGROUND/PURPOSE

Traumatic spinal injury (TSI) is an uncommon source of morbidity and mortality in children. The aim of this study was to describe childhood TSI in a single level 1 urban pediatric trauma center.

METHODS

The authors retrospectively analyzed all children younger than 14 years with TSI, treated at a level I pediatric trauma center between 1991 and 2002 (n = 406, 4% total registry). All children were stratified according to demographics, mechanisms, type and level of injury, radiologic evaluations, associated injuries, and mortality.

RESULTS

The mean age was 9.48 +/- 3.81 years. The most common overall mechanism of injury was motor vehicle crash (MVC; 29%) and ranked highest for infants. Falls ranked highest for ages 2 to 9 years. Sports ranked highest in the 10 to 14 year age group. Paravertebral soft tissue injuries were 68%. The most common injury level was the high cervical spine (O-C4). The incidence of spinal cord injury without radiologic abnormality (SCIWORA) was 6%. Traumatic brain injury (37%) was the most common associated injury. Overall mortality rate was 4% in this urban catchment.

CONCLUSIONS

TSI in children requires a different preventive and therapeutic logarithm compared with that of adults. The potential devastating nature of TSI warrants that the health care team always maintains a high index of suspicion for injury. Future prospective studies are needed to further elucidate injury patterns.