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Rivera GS, Stokum JA, Dean J, Sadowsky CL, Belzberg AJ, Elrick MJ. Nerve Transfer Surgery in Acute Flaccid Myelitis: Prognostic Factors, Long-Term Outcomes, Comparison With Natural History. Pediatr Neurol 2024; 150:74-81. [PMID: 37981447 PMCID: PMC10894453 DOI: 10.1016/j.pediatrneurol.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/13/2023] [Accepted: 10/26/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Nerve transfer surgery is sometimes offered to patients with acute flaccid myelitis (AFM). The objectives of this study were to evaluate surgical efficacy, assess which clinical and neurophysiological data are valuable for preoperative planning, and report long-term outcomes. METHODS This is a single-center, retrospective case series of patients with AFM who received nerve transfer surgery. All patients had preoperative electromyography and nerve conduction studies (EMG/NCS). Matched control muscles that did not receive nerve transfer surgery were defined in the same cohort. RESULTS Ten patients meeting inclusion criteria received a total of 23 nerve transfers (19 upper extremity, four lower extremity). The mean age at symptom onset was 3.8 years, surgery was 0.5 to 1.25 years after diagnosis, and mean follow-up was 2.3 years (range 1.3 to 4.5 years). Among muscles with preoperative strength Medical Research Council (MRC) grade 0, muscles receiving nerve transfers performed significantly better than those that did not (MRC grade 2.17 ± 0.42 vs 0 ± 0, respectively, P = 0.0001). Preoperative EMG/NCS predicted worse outcomes in recipient muscles with more abundant acute denervation potentials (P = 0.0098). Donor nerves found to be partially denervated performed equally well as unaffected nerves. Limited data suggested functional improvement accompanying strength recovery. CONCLUSIONS Nerve transfer surgery is an effective strategy to restore strength for patients with AFM with persistent, severe motor deficits. Postoperative outcomes in patients with complete paralysis are better than the natural history of disease. This study demonstrates the utility of preoperative clinical and electrophysiological data in guiding patient selection for nerve transfer surgery.
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Affiliation(s)
- Glenn S Rivera
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Janet Dean
- Department of Physical Medicine and Rehabilitation, Kennedy Krieger Institute, Baltimore, Maryland
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, Kennedy Krieger Institute, Baltimore, Maryland
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland.
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Lundine JP, Huling JD, Adelson PD, Burd RS, Fuentes M, Haarbauer-Krupa J, Hagen K, Iske C, Koterba C, Kurowski BG, Petrucci S, Rose SC, Sadowsky CL, Westendorf J, Truelove A, Leonard JC. Using Billing Codes to Create a Pediatric Functional Status e-Score for Children Receiving Inpatient Rehabilitation. Arch Phys Med Rehabil 2023; 104:1882-1891. [PMID: 37075966 PMCID: PMC10579455 DOI: 10.1016/j.apmr.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 03/15/2023] [Accepted: 03/24/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Provide proof-of-concept for development of a Pediatric Functional Status eScore (PFSeS). Demonstrate that expert clinicians rank billing codes as relevant to patient functional status and identify the domains that codes inform in a way that reliably matches analytical modeling. DESIGN Retrospective chart review, modified Delphi, and nominal group techniques. SETTING Large, urban, quaternary care children's hospital in the Midwestern United States. PARTICIPANTS Data from 1955 unique patients and 2029 hospital admissions (2000-2020); 12 expert consultants representing the continuum of rehabilitation care reviewed 2893 codes (procedural, diagnostic, pharmaceutical, durable medical equipment). MAIN OUTCOME MEASURES Consensus voting to determine whether codes were associated with functional status at discharge and, if so, what domains they informed (self-care, mobility, cognition/ communication). RESULTS The top 250 and 500 codes identified by statistical modeling were mostly composed of codes selected by the consultant panel (78%-80% of the top 250 and 71%-78% of the top 500). The results provide evidence that clinical experts' selection of functionally meaningful codes corresponds with codes selected by statistical modeling as most strongly associated with WeeFIM domain scores. The top 5 codes most strongly related to functional independence ratings from a domain-specific assessment indicate clinically sensible relationships, further supporting the use of billing data in modeling to create a PFSeS. CONCLUSIONS Development of a PFSeS that is predicated on billing data would improve researchers' ability to assess the functional status of children who receive inpatient rehabilitation care for a neurologic injury or illness. An expert clinician panel, representing the spectrum of medical and rehabilitative care, indicated that proposed statistical modeling identifies relevant codes mapped to 3 important domains: self-care, mobility, and cognition/communication.
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Affiliation(s)
- Jennifer P Lundine
- Department of Speech & Hearing Science, The Ohio State University, Columbus, OH; Division of Clinical Therapies & Inpatient Rehabilitation Program, Nationwide Children's Hospital, Columbus, OH.
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - P David Adelson
- Rockefeller Neuroscience Institute and West Virginia, University Medicine Children's Neuroscience Center, Morgantown, WV
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Molly Fuentes
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | | | - Kaitlin Hagen
- International Center for Spinal Cord Injury, Kennedy Krieger Institute and Johns Hopkins School of Medicine, Baltimore, MD
| | - Cynthia Iske
- Inpatient Rehabilitation Program, Nationwide Children's Hospital, Columbus, OH
| | - Christine Koterba
- Division of Pediatric Psychology and Neuropsychology, Department of Pediatrics, The Ohio State University College of Medicine, and Nationwide Children's Hospital, Columbus, OH
| | - Brad G Kurowski
- Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Departments of Pediatrics and Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Stephanie Petrucci
- Inpatient Rehabilitation Program, Nationwide Children's Hospital, Columbus, OH
| | - Sean C Rose
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
| | - Cristina L Sadowsky
- International Center for Spinal Cord Injury, Kennedy Krieger Institute and Johns Hopkins School of Medicine, Baltimore, MD
| | - Jennifer Westendorf
- Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Annie Truelove
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Julie C Leonard
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH; Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, and Nationwide Children's Hospital, Columbus, OH
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Sadowsky CL. Targeting Sarcopenia as an Objective Clinical Outcome in the Care of Children with Spinal Cord-Related Paralysis: A Clinician's View. Children (Basel) 2023; 10:837. [PMID: 37238385 PMCID: PMC10217275 DOI: 10.3390/children10050837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 04/27/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023]
Abstract
Muscle loss is consistently associated with immobility and paralysis and triggers significant metabolic and functional changes. The negative effects of sarcopenia are amplified in children who are in the process of building their muscle mass as part of development. Because muscle mass loss is consistently associated with increased morbidity and mortality throughout life, optimizing the size and health of muscles following a neurologic injury is an objective target for therapeutic interventions. This review hypothesizes that muscle mass correlates with functional outcomes in children with paralysis related to spinal cord-related neurologic deficits. We propose that the measurement of muscle mass in this population can be used as an objective outcome for clinical long-term care. Finally, some practical clinical approaches to improving muscle mass are presented.
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Affiliation(s)
- Cristina L. Sadowsky
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD 21205, USA;
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
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Hayes LH, Hopkins SE, Liu S, Pardo CA, Garcia-Dominguez MA, Oleszek J, Yea C, Ciftci-Kavaklioglu B, Yeh EA, Dean J, Sadowsky CL, Desai J, Wiegand S, Farias-Moeller R, Nash K, Thakur KT, Vargas WS, Hong-Routson SJ, Yeshokumar A, Zhou MS, Makhani N, Wilson-Murphy M, Bove R, Zhang B, Benson LA. Challenges in the Clinical Recognition of Acute Flaccid Myelitis and its Implications. J Pediatr 2023; 253:55-62.e4. [PMID: 36115622 DOI: 10.1016/j.jpeds.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To explore the challenges in diagnosing acute flaccid myelitis (AFM) and evaluate clinical features and treatment paradigms associated with under recognition. STUDY DESIGN This was a retrospective multicenter study of pediatric patients (≤18 years) who were diagnosed with AFM from 2014 to 2018 using the Centers for Disease Control and Prevention's case definition. RESULTS In 72% of the cases (126 of 175), AFM was not considered in the initial differential diagnosis (n = 108; 61.7%) and/or the patient was not referred for acute care (n = 90; 51.4%) at the initial clinical encounter, and this did not improve over time. Although many features of the presentation were similar in those initially diagnosed with AFM and those who were not; preceding illness, constipation, and reflexes differed significantly between the 2 groups. Patients with a non-AFM initial diagnosis more often required ventilatory support (26.2% vs 12.2%; OR, 0.4; 95% CI, 0.2-1.0; P = .05). These patients received immunomodulatory treatment later (3 days vs 2 days after neurologic symptom onset; 95% CI, -2 to 0; P = .05), particularly intravenous immunoglobulin (5 days vs 2 days; 95% CI, -4 to -2; P < .001). CONCLUSIONS Delayed recognition of AFM is concerning because of the risk for respiratory decompensation and need for intensive care monitoring. A non-AFM initial diagnosis was associated with delayed treatment that could have a clinical impact, particularly as new treatment options emerge.
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Affiliation(s)
- Leslie H Hayes
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, MA
| | - Shanshan Liu
- Department of Neurology and Institutional Centers for Clinical and Translational Research Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MA
| | | | - Joyce Oleszek
- Department of Physical Medicine & Rehabilitation, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Carmen Yea
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - E Ann Yeh
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Janet Dean
- Department of Physical Medicine and Rehabilitation, International Center for Spinal Cord Injury, Johns Hopkins School of Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, International Center for Spinal Cord Injury, Johns Hopkins School of Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Jay Desai
- Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sarah Wiegand
- Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Raquel Farias-Moeller
- Division of Child Neurology, Department of Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Kendall Nash
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA
| | - Kiran T Thakur
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
| | - Wendy S Vargas
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
| | - Sue J Hong-Routson
- Division of Critical Care, Departments of Pediatrics & Neurology, Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anusha Yeshokumar
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Melissa S Zhou
- Department of Pediatrics, Yale School of Medicine, New Haven, CT; Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Naila Makhani
- Department of Pediatrics, Yale School of Medicine, New Haven, CT; Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - Riley Bove
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA
| | - Bo Zhang
- Department of Neurology and Institutional Centers for Clinical and Translational Research Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA.
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Sadowsky CL. Editorial: Women in science - disability, rehabilitation, inclusion research. Front Rehabilit Sci 2022; 3:1054327. [DOI: 10.3389/fresc.2022.1054327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/26/2022] [Indexed: 11/21/2022]
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Sadowsky CL, Sayenko DG. Editorial: Harnessing Neuroplasticity in the Injured Central Nervous System Using Spinal Neuromodulation. Front Rehabilit Sci 2022; 3:841014. [PMID: 36188991 PMCID: PMC9397929 DOI: 10.3389/fresc.2022.841014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/24/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Cristina L. Sadowsky
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, United States
- Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, United States
- *Correspondence: Cristina L. Sadowsky
| | - Dimitry G. Sayenko
- Center for Neuroregeneration, Department of Neurosurgery, Houston Methodist Research Institute, Houston, TX, United States
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Xu AL, Dean JM, Margalit A, Sponseller PD, Sadowsky CL. Bilateral Dega and Varus Derotational Osteotomies for Painful Hip Subluxation in Acute Flaccid Myelitis: A Case Report. J Orthop Case Rep 2022; 12:34-37. [PMID: 37013246 PMCID: PMC10066674 DOI: 10.13107/jocr.2022.v12.i11.3404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/19/2022] [Indexed: 02/12/2023] Open
Abstract
Introduction: Acute flaccid myelitis (AFM) is a recently described diagnosis that primarily impacts the pediatric population. It is characterized by profound proximal muscle weakness with resultant orthopedic manifestations similar to well-known neuromuscular conditions. While the incidence of AFM has been rising, management outcomes are understudied. Here, we describe the first known case of hip reconstruction in AFM. Case Report: A 5-year-old female presented with painful bilateral hip subluxations 2 years after being diagnosed with AFM. Imaging confirmed substantial uncovering of the femoral heads, right greater than left, with reduction on abduction views. Given the extent of her hip pathology and symptoms, she underwent bilateral Dega and varus derotational osteotomies with adductor lengthening, achieving a 35° correction in femoral neck angle and 30° reduction in femoral anteversion bilaterally. At 2 years postoperatively, she was asymptomatic without recurrence of hip displacement. Conclusion:Reconstructive femoral osteotomies can be effective for achieving painless, reduced hips in patients with AFM. Thus, surgeons may reasonably extrapolate current concepts utilized for other low-tone neuromuscular conditions to inform approach to AFM. Keywords: Acute flaccid myelitis, hip displacement, hip reconstruction, varus derotational osteotomy, Dega osteotomy, neuromuscular.
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Murphy OC, Messacar K, Benson L, Bove R, Carpenter JL, Crawford T, Dean J, DeBiasi R, Desai J, Elrick MJ, Farias-Moeller R, Gombolay GY, Greenberg B, Harmelink M, Hong S, Hopkins SE, Oleszek J, Otten C, Sadowsky CL, Schreiner TL, Thakur KT, Van Haren K, Carballo CM, Chong PF, Fall A, Gowda VK, Helfferich J, Kira R, Lim M, Lopez EL, Wells EM, Yeh EA, Pardo CA. Acute flaccid myelitis: cause, diagnosis, and management. Lancet 2021; 397:334-346. [PMID: 33357469 PMCID: PMC7909727 DOI: 10.1016/s0140-6736(20)32723-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022]
Abstract
Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.
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Affiliation(s)
- Olwen C Murphy
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin Messacar
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
| | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Riley Bove
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica L Carpenter
- Department of Neurology, Children's National Health System, Washington, DC, USA
| | - Thomas Crawford
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet Dean
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Roberta DeBiasi
- Department of Pediatric Infectious Diseases, Children's National Health System, Washington, DC, USA
| | - Jay Desai
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raquel Farias-Moeller
- Department of Neurology, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Grace Y Gombolay
- Department of Neurology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Benjamin Greenberg
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Harmelink
- Department of Neurology, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sue Hong
- Division of Pediatric Critical Care, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce Oleszek
- Department of Physical Medicine and Rehabilitation, Children's Hospital Colorado, Aurora, CO, USA
| | - Catherine Otten
- Department of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA; International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Teri L Schreiner
- Department of Child Neurology, Children's Hospital Colorado, Aurora, CO, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Carolina M Carballo
- Department of Infectious Diseases, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina
| | - Pin Fee Chong
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Amary Fall
- Institut Pasteur de Dakar, Département de Virologie, Dakar, Senegal
| | - Vykuntaraju K Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ming Lim
- Children's Neuroscience Center, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, and Faculty of Life Sciences, King's College, London, UK
| | - Eduardo L Lopez
- Department of Infectious Diseases, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina
| | - Elizabeth M Wells
- Department of Neurology, Children's National Health System, Washington, DC, USA
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
Individuals with spinal cord injury/disorder (SCI/D) are at high risk for developing secondary osteoporosis. Bone loss after neurologic injury is multifactorial and is dependent on the time from and extent of neurologic injury. Most bone loss occurs in the first year after complete motor paralysis, and fractures occur most commonly in the distal femur and proximal tibia (paraplegic fracture). The 2019 International Society for Clinical Densitometry Position Statement in SCI establishes that dual-energy X-ray absorptiometry (DXA) can be used to both diagnose osteoporosis and predict lower extremity fracture risk in individuals with SCI/D. Pharmacologic treatments used in primary osteoporosis have mixed results when used for SCI/D-related osteoporosis. Ambulation, standing, and electrical stimulation may be helpful at increasing bone mineral density (BMD) in individuals with SCI/D but do not necessarily correlate with fracture risk reduction. Clinicians caring for individuals with spinal cord-related paralysis must maintain a high index of suspicion for fragility fractures and consider referral for surgical evaluation and management.
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Affiliation(s)
- Cristina L Sadowsky
- International Center for Spinal Cord Injury/Kennedy Krieger Institute, Baltimore, Maryland
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nina Mingioni
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph Zinski
- Department of Cell and Developmental Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Edmiston TL, Elrick MJ, Kovler ML, Jelin EB, Onders RP, Sadowsky CL. Early use of an implantable diaphragm pacing stimulator for a child with severe acute flaccid myelitis-a case report. Spinal Cord Ser Cases 2019; 5:67. [PMID: 31632725 PMCID: PMC6786381 DOI: 10.1038/s41394-019-0207-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction Acute Flaccid Myelitis (AFM) is a recently recognized, polio-like illness of children that can be functionally devastating. Severe cases can lead to ventilatory failure. Incomplete phrenic nerve injuries in other populations has been shown to respond to diaphragmatic stimulation. We therefore proposed an early assessment for incomplete denervation by laparoscopic direct stimulation of the diaphragm and placement of a diaphragmatic pacing system to enhance diaphragm function. Case presentation A 3 year-old girl presented with AFM with clinically and electrodiagnostically severe involvement of all four limbs and muscles of respiration. Direct stimulation of the diaphragm demonstrated contraction and a diaphragmatic stimulator was placed at 3 weeks post presentation. The patient was immediately able to tolerate short bouts of reduced ventilation settings. Electromyography via the pacing wires demonstrated intact motor units consistent with partial denervation/reinnervation in the left hemidiaphragm, and no motor units in the right hemidiaphragm. At three months, she tolerated 6 h of pacing on pressure support setting. At 5 months she demonstrated larger tidal volumes with active pacing than without. Discussion In our experience, AFM patients who require chronic ventilator support are rarely able to be weaned. Despite clinical and surface electrodiagnostic evidence of complete phrenic nerve involvement, the patient's diaphragm responded to direct stimulation. The patient preferred pacing over non-pacing times and showed improved ventilatory ability with pacing as opposed to without, though remains ventilator-dependent. These findings support augmentation of diaphragm function and possible enhanced recovery of spontaneous function.
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Affiliation(s)
- Travis L. Edmiston
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Mathew J. Elrick
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Mark L. Kovler
- Department of Pediatric Surgery, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Eric B. Jelin
- Department of Pediatric Surgery, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Raymond P. Onders
- Department of General Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH USA
| | - Cristina L. Sadowsky
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD USA
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11
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Choe AS, Sadowsky CL, Smith SA, van Zijl PCM, Pekar JJ, Belegu V. Subject-specific regional measures of water diffusion are associated with impairment in chronic spinal cord injury. Neuroradiology 2017; 59:747-758. [PMID: 28597208 DOI: 10.1007/s00234-017-1860-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 05/28/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE We aimed to identify non-invasive imaging parameters that can serve as biomarkers for the integrity of the spinal cord, which is paramount to neurological function. Diffusion tensor imaging (DTI) indices are sensitive to axonal and myelin damage, and have strong potential to serve as such biomarkers. However, averaging DTI indices over large regions of interest (ROIs), a common approach to analyzing the images of injured spinal cord, leads to loss of subject-specific information. We investigated if DTI-tractography-driven, subject-specific demarcation approach can yield measures that are more specific to impairment. METHODS In 18 individuals with chronic spinal cord injury (SCI), subject-specific demarcation of the injury region was performed using DTI tractography, which yielded three regions relative to injury (RRI; regions superior to, at, and below injury epicenter). DTI indices averaged over each RRI were correlated with measures of residual motor and sensory function, obtained using the International Standard of Neurological Classification for Spinal Cord Injury (ISNCSCI). RESULTS Total ISNCSCI score (ISNCSCI-tot; sum of ISNCSCI motor and sensory scores) was significantly (p < 0.05) correlated with fractional anisotropy and axial and radial diffusivities. ISNCSCI-tot showed strongest correlation with indices measured from the region inferior to the injury epicenter (IRRI), the degree of which exceeded that of those measured from the entire cervical cord-suggesting contribution from Wallerian degeneration. CONCLUSION DTI tractography-driven, subject-specific injury demarcation approach provided measures that were more specific to impairment. Notably, DTI indices obtained from the IRRI region showed the highest specificity to impairment, demonstrating their strong potential as biomarkers for the SCI severity.
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Affiliation(s)
- Ann S Choe
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA. .,F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, 707 North Broadway, Baltimore, MD, 21205, USA.
| | - Cristina L Sadowsky
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, 21205, USA.,Physical Medicine and Rehabilitation, Kennedy Krieger Institute, Baltimore, MD, 21205, USA
| | - Seth A Smith
- Radiology and Radiological Sciences, Vanderbilt University, Nashville, TN, 37235, USA.,Vanderbilt University Institute of Imaging Science, Vanderbilt University, Nashville, TN, 37235, USA
| | - Peter C M van Zijl
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.,F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, 707 North Broadway, Baltimore, MD, 21205, USA
| | - James J Pekar
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.,F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, 707 North Broadway, Baltimore, MD, 21205, USA
| | - Visar Belegu
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, 21205, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
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12
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Felter CE, Bentley JA, Sadowsky CL, Wegener ST. Characteristics of individuals seeking activity-based restorative therapy following spinal cord injury: A focus on hope. NeuroRehabilitation 2017; 41:237-240. [PMID: 28505997 DOI: 10.3233/nre-171476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a lack of evidence regarding the psychosocial characteristics of individuals with spinal cord injury (SCI) undergoing activity-based restorative therapy (ABRT) treatment. OBJECTIVES This study seeks to describe the hopefulness of a sample of ABRT participants and describe the relationship between hopefulness and level of rehabilitation engagement. METHODS A prospective cross-sectional cohort study was conducted using a convenience sample of 73 individuals with SCI (mean time since injury = 66.6 months) seeking out-patient, post-acute rehabilitation at a metropolitan ABRT center. Outcome measures included a demographic survey, The Hope Scale, the Patient Health Questionare-9 and the Hopkins Rehabilitation Engagement Rating Scale. RESULTS The ABRT group reported higher levels of hope (M = 54.78, SD = 7.13) than have been reported in a sample of individuals with SCI seeking traditional rehabilitation in the acute (M = 24.58, SD = 4.06) setting. Rehabilitation engagement was not related to hopefulness in the ABRT group. CONCLUSIONS The ABRT group demonstrated high levels of hopefulness. The difference in hopefulness noted between this group and previous studies could be due to the time elapsed since injury, the presence of choice in the rehabilitation process, or the possibility that individuals who chose to participate in ABRT may have inherently different hopefulness characteristics than the broader SCI population.
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Affiliation(s)
- Cara E Felter
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, School of Medicine, Baltimore, MD, USA
| | - Jacob A Bentley
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at Kennedy Krieger Institute, Baltimore, MD, USA
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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13
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Selvarajah S, Haider AH, Schneider EB, Sadowsky CL, Becker D, Hammond ER. Traumatic Spinal Cord Injury Emergency Service Triage Patterns and the Associated Emergency Department Outcomes. J Neurotrauma 2015; 32:2008-16. [PMID: 26102350 DOI: 10.1089/neu.2015.4016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Paralysis is an indication for trauma patients to be preferentially triaged by emergency services to designated level I or II trauma centers (TC). We sought to describe triage practices for patients with acute traumatic spinal cord injury (TSCI) and its associated emergency department (ED) outcomes. Adults ages ≥ 18 years with a diagnosis of acute TSCI (International Classification of Diseases-9: 806 and 952) in the 2006-2011 United States Nationwide Emergency Department Sample were included in these analyses. Outcomes assessed include triage to non-trauma centers (NTC), which is referred to as "under-triage," and ED mortality. Of 117,444 adults with TSCI, 33.4% were under-triaged to NTC. Under-triage was more prevalent with increasing age. Among patients under-triaged to NTC, 37.4% had new injury severity score (NISS) >15, representing severe injuries or polytrauma. Among patients with NISS >15, the odds of ED mortality in NTC were four-fold greater compared to level I trauma centers (TC-I) (adjusted odds ratio [AOR] = 4.06; 95% confidence interval = 1.87-8.79; p < 0.001). In conclusion, under-triage of adults with acute TSCI occurred in at least one-third of the cases. Patients triaged to NTC rather than TC-I experienced higher likelihood of death in the ED even after controlling for personal and injury characteristics. Further research is necessary to elucidate detailed clinical and logistical factors that may be associated with under-triage of acute TSCI, to facilitate interventions aimed at improving patient experience and outcomes.
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Affiliation(s)
- Shalini Selvarajah
- 1 Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine , Baltimore, Maryland.,2 International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at Kennedy Krieger Institute , Baltimore, Maryland
| | - Adil H Haider
- 1 Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine , Baltimore, Maryland.,3 Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Brigham and Women's Hospital , Boston, Massachusetts
| | - Eric B Schneider
- 1 Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Cristina L Sadowsky
- 2 International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at Kennedy Krieger Institute , Baltimore, Maryland
| | - Daniel Becker
- 4 Department of Neurology, Johns Hopkins Hospital , Baltimore, Maryland.,5 International Neurorehabilitation Institute , Lutherville, Maryland
| | - Edward R Hammond
- 2 International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at Kennedy Krieger Institute , Baltimore, Maryland.,6 Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine , Baltimore, Maryland
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14
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Dolbow DR, Gorgey AS, Recio AC, Stiens SA, Curry AC, Sadowsky CL, Gater DR, Martin R, McDonald JW. Activity-Based Restorative Therapies after Spinal Cord Injury: Inter-institutional conceptions and perceptions. Aging Dis 2015; 6:254-61. [PMID: 26236547 DOI: 10.14336/ad.2014.1105] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 10/12/2014] [Accepted: 11/05/2014] [Indexed: 11/01/2022] Open
Abstract
This manuscript is a review of the theoretical and clinical concepts provided during an inter-institutional training program on Activity-Based Restorative Therapies (ABRT) and the perceptions of those in attendance. ABRT is a relatively recent high volume and intensity approach toward the restoration of neurological deficits and decreasing the risk of secondary conditions associated with paralysis after spinal cord injury (SCI). ABRT is guided by the principle of neuroplasticity and the belief that even those with chronic SCI can benefit from repeated activation of the spinal cord pathways located both above and below the level of injury. ABRT can be defined as repetitive-task specific training using weight-bearing and external facilitation of neuromuscular activation. The five key components of ABRT are weight-bearing activities, functional electrical stimulation, task-specific practice, massed practice and locomotor training which includes body weight supported treadmill walking and water treadmill training. The various components of ABRT have been shown to improve functional mobility, and reverse negative body composition changes after SCI leading to the reduction of cardiovascular and other metabolic disease risk factors. The consensus of those who received the ABRT training was that ABRT has much potential for enhancement of recovery of those with SCI. Although various institutions have their own strengths and challenges, each institution was able to initiate a modified ABRT program.
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Affiliation(s)
- David R Dolbow
- University of Southern Mississippi, College of Health, Human Performance and Recreation, Hattiesburg, MS 39406, USA
| | - Ashraf S Gorgey
- Hunter Holmes McGuire VA Medical Center, Spinal Cord Injury and Disorders Center, Richmond, VA 23224, USA. ; Virginia Commonwealth University, School of Medicine, Richmond, VA 23298, USA
| | - Albert C Recio
- Kennedy Krieger Institute, International Center for Spinal Cord Injury, Baltimore MD 21205, USA. ; Johns Hopkins University School of Medicine, Baltimore MD 21205, USA
| | | | - Amanda C Curry
- VA Boston Healthcare System, Physical Medicine and Rehabilitation, West Roxbury, MA 02132, USA
| | - Cristina L Sadowsky
- Kennedy Krieger Institute, International Center for Spinal Cord Injury, Baltimore MD 21205, USA. ; Johns Hopkins University School of Medicine, Baltimore MD 21205, USA
| | - David R Gater
- Penn State Hershey Medical Center and Health System, Hershey, PA 17033, USA. ; Penn State College of Medicine, Hershey, PA 17033
| | - Rebecca Martin
- Kennedy Krieger Institute, International Center for Spinal Cord Injury, Baltimore MD 21205, USA
| | - John W McDonald
- Kennedy Krieger Institute, International Center for Spinal Cord Injury, Baltimore MD 21205, USA. ; Johns Hopkins University School of Medicine, Baltimore MD 21205, USA
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Hammond ER, Recio AC, Sadowsky CL, Becker D. Functional electrical stimulation as a component of activity-based restorative therapy may preserve function in persons with multiple sclerosis. J Spinal Cord Med 2015; 38:68-75. [PMID: 24976037 PMCID: PMC4293536 DOI: 10.1179/2045772314y.0000000238] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE To examine the effect of functional electrical stimulation (FES) cycling on disability progression in persons with multiple sclerosis (MS). DESIGN Retrospective cohort, 40 participants with mean follow-up of 15 months. Setting International Center for Spinal Cord Injury at Kennedy Krieger Institute in Baltimore, a rehabilitation referral center. PARTICIPANTS Forty consecutive persons with MS undergoing rehabilitation from 2007 to 2011, with at least two evaluations based on the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Interventions FES cycling as part of activity-based restorative therapy interventions. OUTCOME MEASURES Change in Expanded Disability Status Scale (EDSS) and ISNCSCI motor, light touch, and pin prick scores from baseline to latest evaluation. RESULTS In 71% of patients, activity-based rehabilitation included FES cycling. There was no disability progression on the EDSS. Lower extremity motor scores improved or stabilized in 75% of patients with primary progressive MS (PPMS), 71.4% with secondary progressive MS (SPMS), and 54.5% with relapsing remitting MS (RRMS). Among patients with improved or stabilized lower extremity motor function, PPMS recorded a mean 9% improvement, SPMS 3% and RRMS 6%. In PPMS, use of FES showed trend towards improvement in motor scores (P = 0.070). CONCLUSIONS FES as part of activity-based rehabilitation may help preserve or improve neurological function in patients with MS.
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Affiliation(s)
| | | | | | - Daniel Becker
- Correspondence to: Daniel Becker, Johns Hopkins School of Medicine, International Neurorehabilitation Institute, 1300 York Road, Building A, Suite 300, Lutherville, MD 21093, USA.
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Selvarajah S, Schneider EB, Becker D, Sadowsky CL, Haider AH, Hammond ER. The Epidemiology of Childhood and Adolescent Traumatic Spinal Cord Injury in the United States: 2007–2010. J Neurotrauma 2014; 31:1548-60. [DOI: 10.1089/neu.2014.3332] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shalini Selvarajah
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric B. Schneider
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel Becker
- Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland
- International Neurorehabilitation Institute, Lutherville, Maryland
| | - Cristina L. Sadowsky
- International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at Kennedy Krieger Institute, Baltimore, Maryland
| | - Adil H. Haider
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Acute Care Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward R. Hammond
- International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at Kennedy Krieger Institute, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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17
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Sadowsky CL, Hammond ER, Strohl AB, Commean PK, Eby SA, Damiano DL, Wingert JR, Bae KT, McDonald JW. Lower extremity functional electrical stimulation cycling promotes physical and functional recovery in chronic spinal cord injury. J Spinal Cord Med 2013; 36:623-31. [PMID: 24094120 PMCID: PMC3831323 DOI: 10.1179/2045772313y.0000000101] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE To examine the effect of long-term lower extremity functional electrical stimulation (FES) cycling on the physical integrity and functional recovery in people with chronic spinal cord injury (SCI). DESIGN Retrospective cohort, mean follow-up 29.1 months, and cross-sectional evaluation. SETTING Washington University Spinal Cord Injury Neurorehabilitation Center, referral center. PARTICIPANTS Twenty-five people with chronic SCI who received FES during cycling were matched by age, gender, injury level, and severity, and duration of injury to 20 people with SCI who received range of motion and stretching. INTERVENTION Lower extremity FES during cycling as part of an activity-based restorative treatment regimen. MAIN OUTCOME MEASURE Change in neurological function: motor, sensory, and combined motor-sensory scores (CMSS) assessed by the American Spinal Injury Association Impairment scale. Response was defined as ≥ 1 point improvement. RESULTS FES was associated with an 80% CMSS responder rate compared to 40% in controls. An average 9.6 CMSS point loss among controls was offset by an average 20-point gain among FES subjects. Quadriceps muscle mass was on average 36% higher and intra/inter-muscular fat 44% lower, in the FES group. Hamstring and quadriceps muscle strength was 30 and 35% greater, respectively, in the FES group. Quality of life and daily function measures were significantly higher in FES group. CONCLUSION FES during cycling in chronic SCI may provide substantial physical integrity benefits, including enhanced neurological and functional performance, increased muscle size and force-generation potential, reduced spasticity, and improved quality of life.
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Affiliation(s)
- Cristina L. Sadowsky
- The International Center for Spinal Cord Injury and the Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, USA; and Department of Physical Medicine and Rehabilitation, Department of Neurology (JWM), John Hopkins, Baltimore, MD USA
| | - Edward R. Hammond
- The International Center for Spinal Cord Injury and the Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, USA
| | - Adam B. Strohl
- Division of Plastic and Reconstructive Surgery, Mount Sinai Medical Center, NY, USA
| | - Paul K. Commean
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Sarah A. Eby
- Department of Physical Medicine and Rehabilitation, Sinai Hospital, Baltimore, MD, USA
| | | | - Jason R. Wingert
- Department of Health and Wellness, University of North Carolina, Asheville, NC, USA
| | - Kyongtae T. Bae
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John W. McDonald
- The International Center for Spinal Cord Injury and the Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, USA; and Department of Neurology, Neurological Surgery, Anatomy and Neurobiology, Washington University School of Medicine, St Louis, MO, USA
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18
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Choe AS, Belegu V, Yoshida S, Joel S, Sadowsky CL, Smith SA, van Zijl PCM, Pekar JJ, McDonald JW. Extensive neurological recovery from a complete spinal cord injury: a case report and hypothesis on the role of cortical plasticity. Front Hum Neurosci 2013; 7:290. [PMID: 23805087 PMCID: PMC3691521 DOI: 10.3389/fnhum.2013.00290] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 06/03/2013] [Indexed: 12/14/2022] Open
Abstract
Neurological recovery in patients with severe spinal cord injury (SCI) is extremely rare. We have identified a patient with chronic cervical traumatic SCI, who suffered a complete loss of motor and sensory function below the injury for 6 weeks after the injury, but experienced a progressive neurological recovery that continued for 17 years. The extent of the patient's recovery from the severe trauma-induced paralysis is rare and remarkable. A detailed study of this patient using diffusion tensor imaging (DTI), magnetization transfer imaging (MTI), and resting state fMRI (rs-fMRI) revealed structural and functional changes in the central nervous system that may be associated with the neurological recovery. Sixty-two percent cervical cord white matter atrophy was observed. DTI-derived quantities, more sensitive to axons, demonstrated focal changes, while MTI-derived quantity, more sensitive to myelin, showed a diffuse change. No significant cortical structural changes were observed, while rs-fMRI revealed increased brain functional connectivity between sensorimotor and visual networks. The study provides comprehensive description of the structural and functional changes in the patient using advanced MR imaging technique. This multimodal MR imaging study also shows the potential of rs-fMRI to measure the extent of cortical plasticity.
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Affiliation(s)
- Ann S Choe
- Department of Neurology, Johns Hopkins University School of Medicine Baltimore, MD, USA ; International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at Kennedy Krieger, Inc. Baltimore, MD, USA ; F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute Baltimore, MD, USA
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19
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Sadowsky CL, Hammond ER, Strohl AB, Commean PK, Eby SA, Damiano DL, Wingert JR, Bae KT, McDonald JW. Lower extremity functional electrical stimulation cycling promotes physical and functional recovery in chronic spinal cord injury. J Spinal Cord Med 2013. [PMID: 24094120 DOI: 10.1179/2045772313y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To examine the effect of long-term lower extremity functional electrical stimulation (FES) cycling on the physical integrity and functional recovery in people with chronic spinal cord injury (SCI). DESIGN Retrospective cohort, mean follow-up 29.1 months, and cross-sectional evaluation. SETTING Washington University Spinal Cord Injury Neurorehabilitation Center, referral center. PARTICIPANTS Twenty-five people with chronic SCI who received FES during cycling were matched by age, gender, injury level, and severity, and duration of injury to 20 people with SCI who received range of motion and stretching. INTERVENTION Lower extremity FES during cycling as part of an activity-based restorative treatment regimen. MAIN OUTCOME MEASURE Change in neurological function: motor, sensory, and combined motor-sensory scores (CMSS) assessed by the American Spinal Injury Association Impairment scale. Response was defined as ≥ 1 point improvement. RESULTS FES was associated with an 80% CMSS responder rate compared to 40% in controls. An average 9.6 CMSS point loss among controls was offset by an average 20-point gain among FES subjects. Quadriceps muscle mass was on average 36% higher and intra/inter-muscular fat 44% lower, in the FES group. Hamstring and quadriceps muscle strength was 30 and 35% greater, respectively, in the FES group. Quality of life and daily function measures were significantly higher in FES group. CONCLUSION FES during cycling in chronic SCI may provide substantial physical integrity benefits, including enhanced neurological and functional performance, increased muscle size and force-generation potential, reduced spasticity, and improved quality of life.
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Affiliation(s)
- Cristina L Sadowsky
- The International Center for Spinal Cord Injury and the Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, USA; and Department of Physical Medicine and Rehabilitation, Department of Neurology (JWM), John Hopkins, Baltimore, MD USA
| | - Edward R Hammond
- The International Center for Spinal Cord Injury and the Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, USA
| | - Adam B Strohl
- Division of Plastic and Reconstructive Surgery, Mount Sinai Medical Center, NY, USA
| | - Paul K Commean
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Sarah A Eby
- Department of Physical Medicine and Rehabilitation, Sinai Hospital, Baltimore, MD, USA
| | | | - Jason R Wingert
- Department of Health and Wellness, University of North Carolina, Asheville, NC, USA
| | - Kyongtae T Bae
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John W McDonald
- The International Center for Spinal Cord Injury and the Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, USA; and Department of Neurology, Neurological Surgery, Anatomy and Neurobiology, Washington University School of Medicine, St Louis, MO, USA
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Abstract
The consequences of neurologic injuries related to transverse myelitis (TM) are long-lasting and require rehabilitative interventions in about two-thirds of cases. Because numerous neural repair mechanisms are dependent on maintenance of an optimal amount of activity both above and below the injury level, rehabilitation and exercise are useful not only for compensatory functional purposes but also as tools in neural system restoration. The application of established neurophysiologic principles to post-TM rehabilitation has substantial impact on optimizing residual functional capabilities while facilitating the processes of central plasticity and reorganization of sensory and motor programming. The process of neurorehabilitation thereby serves both to treat the patient with TM and to help physicians interrogate and dissect the mechanisms involved in spinal cord injury, neuroprotection, and, ultimately, recovery. Post-TM rehabilitation is lifelong and should be integrated into daily living in a home setting as part of the global management of paralysis, a chronic condition with significant comorbidities.
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McDonald JW, Sadowsky CL, Stampas A. The changing field of rehabilitation: optimizing spontaneous regeneration and functional recovery. Handb Clin Neurol 2012; 109:317-336. [PMID: 23098722 DOI: 10.1016/b978-0-444-52137-8.00020-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
For neurorehabilitation of patients with spinal cord injury (SCI), the traditional emphasis on social adaptation is being expanded to include strategies that promote plasticity and regeneration in the central nervous system. Such strategies are needed to optimize recovery of neurological function. For example, the known dependence of most cellular processes on physical activity has led to the novel concept that activity is important in neural repair. This hypothesis has given rise to activity-based restoration therapies (ABRT), which aim to optimize neural activity in the damaged spinal cord, particularly below the injury level. Here, we review the basic science and clinical evidence supporting the lifelong use of ABRT for recovery from spinal cord injury. We define and describe ABRT, and discuss its components, its clinical applications, its relationship to medical management of spinal cord injury, and the potential influences of medications on recovery. We also discuss the health benefits of ABRT under physiological and pathological conditions. We stress that lifelong ABRT is required to optimize return of function and to allow patients to benefit from any "cures" that will be discovered.
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Affiliation(s)
- John W McDonald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Sadowsky CL, McDonald JW. Activity-based restorative therapies: concepts and applications in spinal cord injury-related neurorehabilitation. ACTA ACUST UNITED AC 2009; 15:112-6. [PMID: 19489091 DOI: 10.1002/ddrr.61] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Physical rehabilitation following spinal cord injury-related paralysis has traditionally focused on teaching compensatory techniques, thus enabling the individual to achieve day-to-day function despite significant neurological deficits. But the concept of an irreparable central nervous system (CNS) is slowly being replaced with evidence related to CNS plasticity, repair, and regeneration, all related to persistently maintaining appropriate levels of neurological activity both below and above the area where the damage occurred. It is now possible to envision functional repair of the nervous system by implementing rehabilitative interventions. Making the transition from "bench to bedside" requires careful analysis of existing basic science evidence, strategic focus of clinical research, and pragmatic implementation of new therapeutic tools. Activity, defined as both function specific motor task and exercise appears to be a necessity for optimization of functional, metabolic, and neurological status in chronic paralysis. Crafting a comprehensive rehabilitative intervention focused on functional improvement through neurological gains seems logical. The terms activity-based restorative therapies, activity-based therapies, and activity-based rehabilitation have been coined in the last 10 years to describe a new fundamental approach to deficits induced by neurological paralysis. The goal of this approach is to achieve activation of the neurological levels located both above and below the injury level using rehabilitation therapies. This article reviews basic and clinical science evidence pertaining to implementation of physical activity and exercise as a therapeutic tool in the management of chronic spinal cord-related neurological paralysis.
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Affiliation(s)
- Cristina L Sadowsky
- International Center for Spinal Cord Injury, Department of Physical Medicine and Rehabilitation, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 707 North Broadway, Baltimore, MD 21205, USA.
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Abstract
BACKGROUND By affecting young people during the most productive period of their lives, spinal cord injury is a devastating problem for modern society. A decade ago, treating SCI seemed frustrating and hopeless because of the tremendous morbidity and mortality, life-shattering impact, and limited therapeutic options associated with the condition. Today, however, an understanding of the underlying pathophysiological mechanisms, the development of neuroprotective interventions, and progress toward regenerative interventions are increasing hope for functional restoration. REVIEW SUMMARY This study addresses the present understanding of SCI, including the etiology, pathophysiology, treatment, and scientific advances. The discussion of treatment options includes a critical review of high-dose methylprednisolone and GM-1 ganglioside therapy. The concept that limited rebuilding can provide a disproportionate improvement in quality of life is emphasized throughout. CONCLUSIONS New surgical procedures, pharmacologic treatments, and functional neuromuscular stimulation methods have evolved over the last decades that can improve functional outcomes after spinal cord injury, but limiting secondary injury remains the primary goal. Tissue replacement strategies, including the use of embryonic stem cells, become an important tool and can restore function in animal models. Controlled clinical trials are now required to confirm these observations. The ultimate goal is to harness the body's own potential to replace lost central nervous system cells by activation of endogenous progenitor cell repair mechanisms.
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Affiliation(s)
- Daniel Becker
- Department of Neurology, Spinal Cord Injury Neuro-Rehabilitation Section, Restorative Treatment and Research Program, Washington University School of Medicine, St Louis, Missouri 63108, USA
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McDonald JW, Becker D, Sadowsky CL, Jane JA, Conturo TE, Schultz LM. Late recovery following spinal cord injury. Case report and review of the literature. J Neurosurg 2002; 97:252-65. [PMID: 12296690 DOI: 10.3171/spi.2002.97.2.0252] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors of this prospective, single-case study evaluated the potential for functional recovery from chronic spinal cord injury (SCI). The patient was motor complete with minimal and transient sensory perception in the left hemibody. His condition was classified as C-2 American Spinal Injury Association (ASIA) Grade A and he had experienced no substantial recovery in the first 5 years after traumatic SCI. Clinical experience and evidence from the scientific literature suggest that further recovery would not take place. When the study began in 1999, the patient was tetraplegic and unable to breathe without assisted ventilation; his condition classification persisted as C-2 ASIA Grade A. Magnetic resonance imaging revealed severe injury at the C-2 level that had left a central fluid-filled cyst surrounded by a narrow donutlike rim of white matter. Five years after the injury a program known as "activity-based recovery" was instituted. The hypothesis was that patterned neural activity might stimulate the central nervous system to become more functional, as it does during development. Over a 3-year period (5-8 years after injury), the patient's condition improved from ASIA Grade A to ASIA Grade C, an improvement of two ASIA grades. Motor scores improved from 0/100 to 20/100, and sensory scores rose from 5-7/112 to 58-77/112. Using electromyography, the authors documented voluntary control over important muscle groups, including the right hemidiaphragm (C3-5), extensor carpi radialis (C-6), and vastus medialis (L2-4). Reversal of osteoporosis and an increase in muscle mass was associated with this recovery. Moreover, spasticity decreased, the incidence of medical complications fell dramatically, and the incidence of infections and use of antibiotic medications was reduced by over 90%. These improvements occurred despite the fact that less than 25 mm2 of tissue (approximately 25%) of the outer cord (presumably white matter) had survived at the injury level. The primary novelty of this report is the demonstration that substantial recovery of function (two ASIA grades) is possible in a patient with severe C-2 ASIA Grade A injury, long after the initial SCI. Less severely injured (lower injury level, clinically incomplete lesions) individuals might achieve even more meaningful recovery. The role of patterned neural activity in regeneration and recovery of function after SCI therefore appears a fruitful area for future investigation.
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Affiliation(s)
- John W McDonald
- Department of Neurology and Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri 63108, USA.
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Sadowsky CL. Electrical stimulation in spinal cord injury. NeuroRehabilitation 2002; 16:165-9. [PMID: 11790901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
The use of electricity to stimulate nerves or muscles is nothing new. In the 18th century Galvani recognized that electricity could be converted into "nerve force". Numerous applications of electrical stimulation have been explored, most notably cardiac pacing, cochlear implants or transcutaneous electrical nerve stimulation (TENS) units for pain control. Spinal cord injury (SCI), with its "transecting lesion" that leaves intact nervous system below the injury completely disconnected from the centers that exert motor control provides the ideal opportunity for electrical stimulation use. Multiple applications are being investigated, including those for aerobic conditioning/cardiovascular exercise, cough and breathing assistance, improving bowel and bladder control, erection and ejaculation, hand grasp, spasticity management, neuro-muscular reeducation, standing and walking, etc. This review will focus on innovative and technologically advanced applications of electrical stimulation in the management of patients with spinal cord injury.
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Affiliation(s)
- C L Sadowsky
- Department of Neurology, Spinal Cord Injury Neuro-Rehabilitation Section, Restorative Treatment and Research Program, Washington University School of Medicine, Box 8111, St. Louis, MO 63110, USA.
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Affiliation(s)
- Cristina L. Sadowsky
- Department of Neurology, Spinal Cord Injury Neuro-Rehabilitation Section, Restorative Treatment and Research Program and Department of Neurology, Washington University School of Medicine, Box 8111, St. Louis, MO 63110, USA
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