Longitudinal changes in medical complications in adults with pediatric-onset spinal cord injury

Handrim kinetics and quantitative ultrasound parameters for assessment of subacromial impingement in wheelchair users with pediatric-onset spinal cord injury

BACKGROUND

Most manual wheelchair users with pediatric-onset spinal cord injury (SCI) will experience shoulder pain or pathology at some point in their life. However, guidelines for preservation of the upper limb in children with SCI are limited.

RESEARCH QUESTION

What are the relationships between manual wheelchair handrim kinetics and quantitative ultrasound parameters related to subacromial impingement in individuals with pediatric-onset SCI?

METHODS

Subacromial impingement risk factors including supraspinatus tendon thickness (SST), acromiohumeral distance (AHD), and occupation ratio (OR; SST/AHD) were measured with ultrasound in 11 manual wheelchair users with pediatric-onset SCI. Handrim kinetics were acquired during the stroke cycle, including peak resultant force (FR), peak rate of rise of resultant force (ROR) and fractional effective force (FEF). Variability of handrim kinetics was computed using the coefficient of variation and linear regression was performed to assess correlations between handrim metrics and quantitative ultrasound parameters.

RESULTS

Peak resultant force significantly increased 1.4 % and variability of FEF significantly decreased 8.0 % for every 0.1 cm increase in AHD. FEF decreased 3.5 % for every 0.1 cm increase in SST. Variability of peak resultant force significantly increased 3.6 % and variability of peak ROR of resultant force significantly increased 7.3 % for every 0.1 cm increase in SST. FEF variability significantly decreased 11.6 % for every 0.1 cm increase in SST. Peak ROR significantly decreased 1.54 % with every 10 % increase in OR. FEF variability significantly decreased 1.5 % with every 10 % increase in OR.

SIGNIFICANCE

This is the first study to investigate relationships among handrim kinetics and shoulder structure in manual wheelchair users with pediatric-onset SCI. Associations were identified between subacromial impingement risk factors and magnitude and variability of wheelchair handrim kinetics. These results indicate the critical need to further explore the relationships among wheelchair handrim kinetics, shoulder joint dynamics, and shoulder pathology in manual wheelchair users with pediatric-onset SCI.

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.

The Influence of Age at Pediatric-Onset Spinal Cord Injury and Years of Wheelchair Use on Shoulder Complex Joint Dynamics During Manual Wheelchair Propulsion

Objective

To assess the association of age at pediatric-onset spinal cord injury (SCI) and years of manual wheelchair use with shoulder dynamics.

Design

Upper extremity kinematics and hand-rim kinetics were obtained during manual wheelchair propulsion. An inverse dynamics model computed three-dimensional acromioclavicular, sternoclavicular, and glenohumeral joint dynamics. Linear mixed effects models evaluated the association of age at injury onset and years of wheelchair use with shoulder dynamics.

Setting

Motion laboratory within a children's hospital.

Participants

Seventeen manual wheelchair users (N=17; 6 female, 11 male; mean age: 17.2 years, mean age at SCI onset: 11.5 years) with pediatric-onset SCI (levels: C4-T11) and International Standards for Neurological Classification of SCI grades: A (11), B (3), C (2), and N/A (2).

Interventions

Not applicable.

Main Outcome Measures

Acromioclavicular, sternoclavicular, and glenohumeral angles and ranges of motion, and glenohumeral forces and moments.

Results

We observed a decrease in maximum acromioclavicular upward rotation (ß [95% confidence interval {CI}]=3.02 [0.15,5.89], P=.039) and an increase in acromioclavicular downward/upward rotation range of motion (ß [95% CI]=0.44 [0.08,0.80], P=.016) with increasing age at SCI onset. We found interactions between age at onset and years of use for maximum glenohumeral abduction (ß [95% CI]=0.16 [0.03,0.29], P=.017), acromioclavicular downward/upward rotation range of motion (ß [95% CI]=-0.05 [-0.09,-0.01], P=.008), minimum acromioclavicular upward rotation (ß [95% CI]=-0.34 [-0.64,-0.04], P=.026). A decrease in glenohumeral internal rotation moment (ß [95% CI]=-0.09 [-0.17,-0.009], P=.029) with increasing years of use was found.

Conclusions

Age at injury and the years of wheelchair use are associated with shoulder complex biomechanics during wheelchair propulsion. These results are noteworthy, as both age at SCI onset and years of wheelchair use are considered important factors in the incidence of shoulder pain. These results suggest that investigations of biomechanical changes over the lifespan are critical.

Transitioning between paediatric and adult healthcare services: a qualitative study of the experiences of young people with spinal cord injuries and parents/caregivers

OBJECTIVES

Healthcare transition (HCT) interventions are pivotal to paediatric rehabilitation. However, there has been limited research focusing on HCT in young people with spinal cord injury (SCI). To date, little has been reported on key factors that may contribute to a positive or negative transition experience and what, if any, are the gaps in the transition process. This study explored the experiences of transition from paediatric to adult healthcare for young people with SCI and parents/caregivers in pursuit of co-designing and developing an intervention to support transition.

DESIGN, SETTING AND PARTICIPANTS

This qualitative study forms part of the planning phase of a larger participatory action research project. It supports obtaining a rich understanding of the phenomenon and the issues and actions necessary to achieve change. Semi-structured individual interviews were conducted online between April and June 2021 with young people with SCI and parents/caregivers who had transitioned or were preparing for the transition from paediatric to adult healthcare in NSW, Australia. The interviews were analysed using an inductive reflexive thematic analysis approach.

RESULTS

The study recruited nine participants, five young people with SCI and four parents/caregivers. The interviews provided invaluable insight into young people with SCI and their parents'/caregivers' experiences of HCT. As HCT experiences were often less than optimal and needs were not adequately met, some recommendations were offered. These included a coordinated and streamlined handover from paediatric to adult healthcare providers, and a 'one-stop shop' for young people with SCI and their parents/caregivers to access transition information, such as how it occurs, who to call for ongoing support and advice, and tips on how to transition successfully.

CONCLUSION

Providing a coordinated and streamlined handover process as well as access to more context-related information could improve the transition experiences of young people with SCI and parents/caregivers, resulting in improved health outcomes and greater independence.

TRIAL REGISTRATION

ACTRN12621000500853.

Evaluation of pediatric-specific resources to support utilization of the Wheelchair Skills Training Program by the users of the resources: a descriptive qualitative study

BACKGROUND

Children's ability to engage in meaningful activities is positively influenced by their ability to move independently. Preliminary evidence in children suggests that wheelchair skills training improves wheelchair skills, which are important for independent mobility. The Wheelchair Skills Training Program is a standardized program to teach wheelchair skills. However, it is underutilized in pediatric rehabilitation settings. To increase its utilization, 3 pediatric-specific Wheelchair Skills Training Program resources related to indoor skills were developed (i.e., a storybook, four instructional posters, and a training workbook). This study aimed to describe occupational therapists' (OTs) and pediatric manual wheelchair users' (PMWUs) perceived satisfaction with the storybook, instructional posters and training workbook, and to explore their perceptions regarding the usability, relevance, and feasibility of these resources in pediatric rehabilitation settings.

METHODS

A descriptive qualitative design was used. Convenience samples of OTs and PMWUs were recruited in a rehabilitation center and affiliated schools. A focus group with OTs and semi-structured interviews with PMWUs were conducted by videoconference to obtain participants' feedback on the resource prototypes and suggestions for improvement. Data were deductively analyzed using the Framework method.

RESULTS

Eight OTs and 5 PMWUs expressed general satisfaction with the resources, describing them as usable, relevant, and feasible to integrate into wheelchair skills training with novice wheelchair users and younger children. All OTs and 3 PMWUs expressed the desire to use the resources for wheelchair skills training. Two PMWUs perceived the resources were not relevant to them because they already mastered the skills. The participants suggested minor modifications for improving the resources (e.g., more action in the story, increased precision of illustrations related to the characters' position in the wheelchair).

CONCLUSION

OTs and PMWUs were satisfied with the resources, perceiving them to be applicable for training wheelchair skills among young children and novice wheelchair users. The resources represent a concrete solution to facilitate the use of the Wheelchair Skills Training Program in pediatric rehabilitation settings. Additional resources are needed to better reach older and more experienced PMWUs (i.e., of intermediate and advanced skill levels).

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

Objectives

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

Methods

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

Results

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

Conclusion

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

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Understanding transition for youth with spinal cord injury: Youth and caregiver perceptions

Objective: The purpose of this study is to understand facilitators of and barriers to achieving positive transition results among youth with spinal cord injury (SCI), and to identify areas for intervention to improve transition outcomes. Design: This study utilized qualitative methods and analysis was completed using Interpretive Phenomenological Analysis. Participants: Participants included adolescents (n = 9, range = 13-18 years old), young adults (n = 14, range = 22-30 years old) with an SCI, and their respective caregivers (n = 17). Results: The majority of participants had paraplegia (78%) and complete injuries (52%). The majority of caregivers were mothers (88%). Two primary themes were identified: Facilitators of Transition and Barriers to Transition. From these, five subthemes were developed for each category. Conclusion: Youth with SCI and caregivers would benefit from organizations offering dynamic and progressive care options including social reintegration programs, peer-mentoring opportunities, and programs to teach individuals with SCI and families ways to develop motivation, resilience, and independent living skills. Last, better communication among healthcare providers and an increase of interdisciplinary and accessible adult healthcare facilities would foster greater transition successes for individuals with SCI.

Training Youth With SCI to Improve Efficiency and Biomechanics of Wheelchair Propulsion: A Pilot Study

Background: Long-term manual wheelchair users are at an increased risk of developing upper extremity (UE) joint pain and injuries due to the repetitive nature of wheelchair propulsion. Youth who sustain spinal cord injuries (SCIs) may be at even greater risk due to the many years they may be wheelchair dependent. There has been a decreasing trend in duration of initial rehabilitation, therefore little time is spent on training of proper wheelchair propulsion. An objective evaluation along with proper training may help prevent the risk of UE pain and injuries over time. Objective: To develop a training program to improve the efficiency and biomechanics of wheelchair propulsion in youth with SCI and evaluate changes made following propulsive training. Methods: Manual wheelchair users between 4 and 21 years old with SCI were recruited from one hospital. Demographic and clinical measures were collected and the subjects completed the Wheelchair User's Shoulder Pain Index. SmartWheel metrics were collected at baseline and following propulsive training on a roller system. Analyses assessed differences in SmartWheel metrics pre and post training. Results: The 23 participants were between 7 and 19 years of age; 57% were male and 69% with paraplegia. Significant improvements were found for SmartWheel metrics of peak backwards force that improved from -3.08 Newtons (N) ± 2.1 pre training to -2.37 N ± 1.9 (p = .041) post training and for push mechanical effectiveness that improved from .575 ± .14 at baseline to .631 ± .17 post training (p = .033). Conclusion: Our results suggest that an objective wheelchair assessment and propulsive training may be a valuable tool for youth with SCI.

Clinical feasibility of gait training with a robotic exoskeleton (WPAL) in an individual with both incomplete cervical and complete thoracic spinal cord injury: A case study

BACKGROUND

Patients with tetraplegia can achieve independent gait with lateral-type powered exoskeletons; it is unclear whether medial-type powered exoskeletons allow for this.

OBJECTIVE

To investigate gait training with a medial-type powered exoskeleton wearable power-assist locomotor (WPAL) in an individual with incomplete cervical (C5) and complete thoracic (T12) spinal cord injury (SCI).

METHODS

The 60-session program was investigated retrospectively using medical records. Upon completion, gait performance was examined using three-dimensional motion analyses and surface electromyography (EMG) of the upper limbs.

RESULTS

The subject achieved independent gait with WPAL and a walker in 12 sessions. He continuously extended his right elbow; his left elbow periodically flexed/extended. His pelvic inclination was larger than the trunk inclination during single-leg stance. EMG activity was increased in the left deltoid muscles during ipsilateral foot-contact. The right anterior and medial deltoid muscle EMG activity increased just after foot-off for each leg, as did the right biceps activity. Continuous activity was observed in the left triceps throughout the gait cycle; activity was unclear in the right triceps.

CONCLUSIONS

These results suggest the importance of upper limb residual motor function, and may be useful in extending the range of clinical applications for robotic gait rehabilitation in patients with SCI.

Poor sleep in adults with pediatric-onset spinal cord injury: associations with pain, health, and activity

OBJECTIVE

To investigate medical complications that increase risk for poor sleep in adults with pediatric-onset spinal cord injury (SCI) and explore the relation of poor sleep to psychosocial outcomes.

METHOD

This was a cross-sectional study of individuals with pediatric-onset SCI interviewed between 2011-2015. Participants were recruited from a pediatric specialty hospital and answered questions about demographics, injury characteristics, pain, and medical complications and completed standardized outcome measures, including: Pittsburgh Sleep Quality Index, SF12v2 Health Survey, Craig Handicap Assessment and Recording Technique (CHART), and Subjective Happiness Scale.

RESULTS

The study included 180 participants between the ages of 19 and 51 (M=34.20 y; SD=7.28) who sustained their SCI before the age of 19 (M=13.48y; SD=4.59). Participants were predominantly male (62%) and Caucasian (84%). A majority had tetraplegia (56%) and complete injuries (74%). Poor sleep occurred with greater frequency in those with tetraplegia and who were unemployed. Neck (OR=2.80, P = 0.001), shoulder (OR=2.15, P = 0.011), arm (OR=3.06, P = 0.004), and lower extremity pain (OR=2.72, P = 0.004) were associated with increased risk of poor sleep. In a logistic regression analysis, chronic medical conditions and continuous pain were most likely to be associated with poor sleep. Individuals with poor sleep reported lower levels of mobility, perceived health, and subjective happiness.

CONCLUSION

Pain and secondary complications significantly increase the odds of poor sleep. Furthermore, poor sleep is associated with decreased mobility and measures of well-being. Preventive measures to reduce risk factors and improve sleep quality after pediatric-onset SCI should be considered.

Differences in health, participation and life satisfaction outcomes in adults following paediatric- versus adult-sustained spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To compare differences in self-reported health status, participation and life satisfaction outcomes between adults with a spinal cord injury (SCI) sustained during paediatric (P) versus adulthood (A) years.

SETTING

Ontario, Canada.

METHODS

Secondary analysis of data from the Study of Health and Activity in People with SCI. Eighty-seven participants who sustained an SCI prior to age 19 (M±s.e.=25±1.5 years postinjury (YPI)) were matched for lesion level (C2-L5), severity (complete/incomplete), gender, age, education and ethnicity with 87 participants who sustained an SCI at ⩾age 19 years (M_YPI=12.8±1.1).

RESULTS

Those with a paediatric SCI reported significantly less pain, fewer visits to the physician in the past year, greater functional independence, social participation, occupational participation and minutes per day of moderate-to-vigorous physical activity than those who sustained an SCI in adulthood. No significant differences were found for the measures of depression, perceived health status or life satisfaction (P>0.05). With the exception of moderate-to-vigorous physical activity and visits to the physician in the past year, between-group differences were independent of YPI.

CONCLUSIONS

Regardless of time since injury, people who sustained a paediatric SCI reported better health and greater participation than those injured in adulthood. Nevertheless, both groups scored well below able-bodied normative values for all measures. The results highlight the importance of a comprehensive life-course approach to SCI rehabilitation, irrespective of age at the time of injury.

Biomechanics of Pediatric Manual Wheelchair Mobility

Currently, there is limited research of the biomechanics of pediatric manual wheelchair mobility. Specifically, the biomechanics of functional tasks and their relationship to joint pain and health is not well understood. To contribute to this knowledge gap, a quantitative rehabilitation approach was applied for characterizing upper extremity biomechanics of manual wheelchair mobility in children and adolescents during propulsion, starting, and stopping tasks. A Vicon motion analysis system captured movement, while a SmartWheel simultaneously collected three-dimensional forces and moments occurring at the handrim. A custom pediatric inverse dynamics model was used to evaluate three-dimensional upper extremity joint motions, forces, and moments of 14 children with spinal cord injury (SCI) during the functional tasks. Additionally, pain and health-related quality of life outcomes were assessed. This research found that joint demands are significantly different amongst functional tasks, with greatest demands placed on the shoulder during the starting task. Propulsion was significantly different from starting and stopping at all joints. We identified multiple stroke patterns used by the children, some of which are not standard in adults. One subject reported average daily pain, which was minimal. Lower than normal physical health and higher than normal mental health was found in this population. It can be concluded that functional tasks should be considered in addition to propulsion for rehabilitation and SCI treatment planning. This research provides wheelchair users and clinicians with a comprehensive, biomechanical, mobility assessment approach for wheelchair prescription, training, and long-term care of children with SCI.

Longitudinal employment outcomes in adults with pediatric-onset spinal cord injury

STUDY DESIGN

Longitudinal survey.

OBJECTIVES

To determine in adults with pediatric-onset spinal cord injury (SCI) employment outcomes, longitudinal changes in employment over time and changes in psychosocial outcomes associated with employment status.

SETTING

Community setting.

METHODS

Adults who had sustained a SCI before 19 years of age and had completed at least three consecutive annual interviews were included in the study. Generalized estimating equation models were formulated to obtain odds ratio (OR) of change in employment status and outcomes over time.

RESULTS

Total 1691 interviews were conducted in 283 participants, 182 men and 101 women (88% Caucasian; age at baseline, 27.3±3.7 years; duration at baseline, 12.7±5.0 years). At the last interview (age, 34.4±5.2 years; duration, 19.9±6.1 years), 49.5% were employed and 47.0% had a baccalaureate or post-baccalaureate degree. There was no significant change in employment status over time (OR 1.01, confidence interval (CI) 0.98-1.04). Odds of employment increased over time in participants who were women (1.04, CI 1.00-1.08), married (1.05, CI 1.02-1.08) and attained baccalaureate (1.03, CI 1.00-1.07) or post-baccalaureate (1.05, CI 1.02-1.08) degree. Employment odds decreased with occurrence of autonomic dysreflexia (0.80, CI 0.65-0.99), spasticity (0.80, CI 0.59-0.99) or chronic medical condition (0.83, CI 0.71-0.98). Life satisfaction scores increased over time in those who remained employed (1.11, CI 1.01-1.22); odds of depression increased over time in those who remained unemployed (1.13, CI 1.04-1.23).

CONCLUSION

Employment status remained relatively stable in adults with pediatric-onset SCI; however, changes in employment were associated with education, secondary health conditions and psychosocial well-being.