Functional recovery in children and adolescents with spinal cord injury

A National Survey of Pediatric Post-Acute Care Facilities

OBJECTIVES

To identify and geolocate pediatric post-acute care (PAC) facilities in the United States.

DESIGN

Cross-sectional survey using both online resources and telephone inquiry.

SETTING

All 50 U.S. states surveyed from June 2022 to May 2023. Care sites identified via state regulatory agencies and the Centers for Medicare & Medicaid Services.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Number, size, and type of facility, scope of practice, and type of care provided. One thousand three hundred fifty-five facilities were surveyed; of these, 18.6% (252/1355) were pediatric-specific units or adult facilities accepting some pediatric patients. There were 109 pediatric-specific facilities identified within 39 U.S. states. Of these, 38 were freestanding with all accepting children with tracheostomies, 97.4% (37/38) accepting those requiring mechanical ventilation via tracheostomy, and 81.6% (31/38) accepting those requiring parenteral nutrition. The remaining 71 facilities were adult facilities with embedded pediatric units or children's hospitals with 88.7% (63/71), 54.9% (39/71), and 54.9% (39/71), accepting tracheostomies, mechanical ventilation via tracheostomy, and parenteral nutrition, respectively. Eleven states lacked any pediatric-specific PAC units or facilities.

CONCLUSIONS

The distribution of pediatric PAC is sparse and uneven across the United States. We present an interactive map and database describing these facilities. These data offer a starting point for exploring the consequences of pediatric PAC supply.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

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.

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.

Training to Improve Walking after Pediatric Spinal Cord Injury: A Systematic Review of Parameters and Walking Outcomes

Walking or locomotor training is often initiated following pediatric spinal cord injury (SCI). There is no synthesis of the literature on interventions targeting walking for pediatric SCI, although this would assist future clinical trials and interventions. To address this need, we completed a systematic review to summarize the who, what, when, and how of walking interventions in children with SCI. Participant characteristics, training parameters, and walking outcomes with training in pediatric SCI were identified and compared with training parameters and outcomes in adults with SCI. The PubMed, Medline, AMED, Embase, PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL databases were searched for studies that included participants aged 1-17 years with a SCI acquired post-birth, physical interventions, and pre- and post-training walking measures. Two researchers evaluated each study's risk of bias using a domain-based approach. Training parameters and walking outcomes were extracted. Total training duration (duration × frequency × number of weeks) was calculated. Thirteen pediatric studies (n = 43 children) were included; all but one were case series/reports. Risk of bias was high in the pediatric studies. A 2012 adult review was updated (11 studies added). As with adults, the training durations, frequencies, and modes used with the children varied; however, overground walking practice was included in 10/13 pediatric studies. Improvements in walking capacity, speed, and distance were comparable between children and adults. There was a trend for greater gains with greater total training durations. There is a paucity of high-quality research examining interventions targeting walking after pediatric SCI; however, intensive training, including practice overground, results in notable improvements.

Conventional physical therapy and physical therapy based on reflex stimulation showed similar results in children with myelomeningocele

We aimed to investigate whether infants with myelomeningocele would improve their motor ability and functional independence after ten sessions of physical therapy and compare the outcomes of conventional physical therapy (CPT) to a physical therapy program based on reflex stimulation (RPT). Twelve children were allocated to CPT (n = 6, age 18.3 months) or RPT (n = 6, age 18.2 months). The RPT involved proprioceptive neuromuscular facilitation. Children were assessed with the Gross Motor Function Measure and the Pediatric Evaluation of Disability Inventory before and after treatment. Mann-Whitney tests compared the improvement on the two scales of CPT versus RPT and the Wilcoxon test compared CPT to RPT (before vs. after treatment). Possible correlations between the two scales were tested with Spearman correlation coefficients. Both groups showed improvement on self-care and mobility domains of both scales. There were no differences between the groups, before, or after intervention. The CPT and RPT showed similar results after ten weeks of treatment.

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.

Responsiveness of the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test in measuring functional outcomes for inpatient pediatric rehabilitation

PURPOSE

Responsiveness of the PEDI-CAT Mobility, Daily Activities, and Social/Cognitive domains and Wheelchair subdomain was evaluated for youth admitted to a pediatric post-acute care hospital.

METHODS

Inpatients ages 2-21 years, with a length of stay of ≥ 5 days and with both admission and discharge scores were included. The difference between mean admission and discharge PEDI-CAT scaled scores were analyzed using paired t-tests. Effect sizes, standard response means (SRMs), and minimal detectable change values were calculated. Score comparison between diagnostic subgroups (Traumatic Brain Injury, Neurological, Orthopedic, Medical) and age groups ( ≤ 5, > 5 but < 13, ≥ 13 years) were evaluated for the Mobility domain.

RESULTS

Sample size differed by domain with 66 Mobility, 30 Daily Activities, 19 Social/Cognitive and 9 Wheelchair subdomain pairs. Significant differences were found for all domains when mean admission and discharge scaled scores were compared. Moderate to large effect sizes and SRMs were found for the Mobility and Daily Activities domains and Wheelchair subdomain. Small effect size but large SRM was found for the Social/Cognitive domain. The Mobility domain was also responsive to changes in all diagnostic and age groups.

CONCLUSION

The PEDI-CAT was responsive to functional changes for youth discharged from an inpatient pediatric rehabilitation hospital.

Pediatric Post-Acute Hospital Care: Striving for Identity and Value

The landscape of hospital care for children is changing. Hospital clinicians are challenged to provide high-quality care to 2 increasingly complex groups of children: (1) healthy children admitted for high-severity acute illnesses or injury and (2) children admitted with lifelong, and often disabling, chronic conditions. Hospitalizations for both of these groups are becoming more prevalent, lengthy, and costly. In many situations, these children need weeks, or sometimes months, to recover from their illness or injury, with a sustained intensity of daily caregiving needs throughout their recovery period. Pediatric post-acute hospital care is a little-known and underused option in pediatric health care that could substantially help these children stabilize in a less restrictive and less costly environment than acute care hospitals can provide. In this commentary, we (1) propose the need and place for pediatric post-acute care hospitals along the continuum of care, (2) discuss the characteristics of children currently cared for in pediatric post-acute care hospitals, (3) suggest research opportunities and challenges, and (4) present issues related to the cost and value of pediatric post-acute care hospitals.

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.

Acute paediatric paraplegia: a case series review

Paediatric paraplegia resulting from spinal cord pathology of any cause is rare; hence prognostic information for children less than 16 years is limited. This case series review aims to ascertain all cases of paediatric paraplegia from 1997 to 2012 in the former Northern Region of England.

METHODS

Children presenting with sudden paraplegia before the age of 16 years were multiply ascertained from databases in the regional paediatric neurology, neuroradiology, neuro-oncology and adult spinal injuries units. Data were obtained from retrospective case note review.

RESULTS

A total of 44 cases (24 female) were identified. The incidence is estimated at 0.49 per 100,000 children under 16/year (95% confidence interval 0.41-0.57). Mean age of onset was 8.8 years and the most common aetiology was inflammatory. Twelve months post presentation, mortality was zero and a good outcome (defined as Gross Motor Function Classification System grades I or II) was seen in 66.6%. Motor outcome at 12 months was associated with the presence of bladder/bowel signs at presentation, previous viral illness and initial severity of paraplegia. Bladder signs at presentation were the strongest predictor of prognosis (OR for poor motor outcome 10.3). We were unable to demonstrate a relationship between aetiology and late outcome.

CONCLUSION

Paediatric paraplegia is rare. Mortality rates are low and 66.6% have a good outcome with fully or nearly independent walking. Bladder signs are the strongest predictor of prognosis.

Lessons from use of the Pediatric Evaluation of Disability Inventory: where do we go from here?

PURPOSE

The purpose of this article is to review the innovations, applications, and effect of the original Pediatric Evaluation of Disability Inventory (PEDI) published in 1992 and to describe planned revisions.

SUMMARY OF KEY POINTS

During the past decade, the PEDI has helped to shift thinking from a developmental to a functional focus. Using the PEDI, researchers and clinicians worldwide have highlighted variations in functional skill acquisition in clinical populations, the importance of recognizing cultural differences, and the value of documenting functional progress in relation to interventions.

CONCLUSIONS

The PEDI has had a rich tradition in helping to document functional development. New methods are proposed for the next generation of the PEDI by using item banks and computer adaptive testing.

RECOMMENDATIONS FOR CLINICAL PRACTICE

The computer adaptive testing feature and the revised and expanded content of the new PEDI will enable therapists to more efficiently assess children's functioning to a broader age group of children.