The Pittsburgh Impairment Testing Tool (PITT) for Spina Bifida Can Predict Ambulation and Transfer Ability in Adults with Spina Bifida.

OBJECTIVE: The aim of this study was to evaluate the predictive accuracy of the Pittsburgh Impairment Testing Tool (PITT). It was hypothesized that PITT would have a good overall accuracy (>80%) for predicting both ambulation and transfer ability and that overall accuracy of PITT would be higher than that of other scales. DESIGN: A retrospective chart review was used to classify 409 adults with spina bifida according to seven neurological scales. A Naïve Bayes classifier was used to obtain accuracy estimates for predicting both ambulation and transfer ability as a function of each scale. RESULTS: PITT was the only scale demonstrating >80% overall accuracy for predicting both ambulation and transfer ability. While several scales demonstrated >80% overall accuracy in predicting transfer ability, none were useful in predicting inability to transfer. Inability to transfer was difficult for all tools to predict. CONCLUSION: PITT demonstrated good overall accuracy for predicting both ambulation and transfer ability. Sensory and anatomic levels were less useful than motor level in predicting functional ability.

Discovering Provider Awareness of Mobility Assistive Technologies and Clinical Guidelines- A Comparative Analysis with Consumer Responses.

OBJECTIVE: This study aims to enhance the accessibility and quality of mobility assistive technology (MAT) by investigating and bridging knowledge gaps between MAT providers and consumers with ambulatory limitations. DESIGN: A survey was conducted among MAT providers in the United States, consisting of sections on awareness, knowledge importance and desire, and knowledge sources. The responses were compared to data collected from consumers in a previous study. RESULTS: A total of 144 MAT providers participated, with 60% having received academic or professional training in relevant fields. Analysis revealed significant knowledge gaps between providers and consumers, particularly in AT assessment tools and knowledge sources. Moderate gaps were also observed in areas such as clinical practice guidelines, desired MAT information, and knowledge sources. However, the gaps in other areas were relatively small. CONCLUSION: This study highlights the knowledge gaps between MAT providers and consumers, hindering the optimal utilization and fulfillment of user needs. Providers possess valuable information that consumers may lack, positioning them as primary knowledge sources. Addressing these gaps through targeted interventions, improved communication channels, and enhanced education can enhance the utilization of MAT and improve outcomes for individuals with ambulatory limitations.

Toward the Identification of Distinct Phenotypes: Research Protocol for the Low Back Pain Biological, Biomechanical, and Behavioral (LB3P) Cohort Study and the BACPAC Mechanistic Research Center at the University of Pittsburgh.

As a member of the Back Pain Consortium (BACPAC), the University of Pittsburgh Mechanistic Research Center's research goal is to phenotype chronic low back pain using biological, biomechanical, and behavioral domains using a prospective, observational cohort study. Data will be collected from 1,000 participants with chronic low back pain according to BACPAC-wide harmonized and study-specific protocols. Participation lasts 12 months with one required in person baseline visit, an optional second in person visit for advanced biomechanical assessment, and electronic follow ups at months 1, 2, 3, 4, 5, 6, 9, and 12 to assess low back pain status and response to prescribed treatments. Behavioral data analysis includes a battery of patient-reported outcomes, social determinants of health, quantitative sensory testing, and physical activity. Biological data analysis includes omics generated from blood, saliva, and spine tissue. Biomechanical data analysis includes a physical examination, lumbopelvic kinematics, and intervertebral kinematics. The statistical analysis includes traditional unsupervised machine learning approaches to categorize participants into groups and determine the variables that differentiate patients. Additional analysis includes the creation of a series of decision rules based on baseline measures and treatment pathways as inputs to predict clinical outcomes. The characteristics identified will contribute to future studies to assist clinicians in designing a personalized, optimal treatment approach for each patient.

Establishing Content Validity Evidence of the Pittsburgh Impairment Testing Tool (PITT) for Adults With Spina Bifida.

Background: Current scales to measure motor impairment in adults with spina bifida (SB) are limited by their complexity, variable interpretation (i.e., subjectively defined impairment levels), or inclusion of muscles groups that are not always practical to test in a clinical setting. Objectives: A novel motor impairment tool for adults with SB was evaluated for content validity. The tool uses findings from the manual muscle testing of hip flexion and knee extension to categorize individuals into four motor impairment groups. Methods: Expert feedback was obtained on the tool, and content validity was measured using Lawshe's content validity ratio (CVR) with critical values recommended by Ayre and Scally. Data from phase 1 and phase 2 were used to revise the survey and calculate the CVR of the tool, respectively (benchmark: CVR ≥ 0.636). Results: Of the 26 experts recruited, 17 received the survey and 15 participated in either phase 1 (n = 6) or 2 (n = 11). The CVR values for each impairment group were as follows: intact strength (0.95), thoracic strength (0.90), hip flexor dominant strength (0.89), and knee extensor dominant strength (0.82). The CVR of the tool overall was 0.89. Qualitative expert feedback revealed common barriers to manual muscle testing and suggestions for improving the tool. However, experts also noted the value in preserving the simplicity of the tool. Conclusion: The high content validity, coupled with expert feedback, suggests the tool may give clinicians and researchers a practical method of classifying an individual's extent of motor impairment.

Factors Associated With Burnout in Physical Medicine and Rehabilitation Residents in the United States.

OBJECTIVES: The aims of the study were to determine the prevalence of burnout in physical medicine and rehabilitation residents in the United States and to identify the personal- and program-specific characteristics most strongly associated with residents reporting burnout. DESIGN: This was a cross-sectional survey of US physical medicine and rehabilitation residents. Emotional exhaustion, depersonalization, and burnout were assessed using two validated items from the Maslach Burnout Inventory. Associations of burnout with demographics and personal factors, residency program characteristics, perceived program support, and work/life balance were evaluated. RESULTS: The survey was completed by 296 residents (22.8%), with 35.8% of residents meeting the criteria for burnout. Residents' perception of not having adequate time for personal/family life was the factor most strongly associated with burnout (χ2 = 93.769, P < 0.001). Residents who reported inappropriate clerical burden and working more than 50 hrs/wk on inpatient rotations were most likely to report that they did not have adequate time for personal/family life. Faculty support (χ2 = 41.599, P < 0.001) and performing activities that led residents to choose physical medicine and rehabilitation as a specialty (χ2 = 93.082, P < 0.001) were protective against burnout. CONCLUSIONS: Residents reporting having inadequate time for their personal/family life was most strongly associated with physical medicine and rehabilitation resident burnout, although many personal and program characteristics were associated with burnout.

Within-subject effects of standardized prosthetic socket modifications on physical function and patient-reported outcomes.

BACKGROUND: Among the challenges of living with lower limb loss is the increased risk of long-term health problems that can be either attributed directly to the amputation surgery and/or prosthetic rehabilitation or indirectly to a disability-induced sedentary lifestyle. These problems are exacerbated by poorly fit prosthetic sockets. There is a knowledge gap regarding how the socket design affects in-socket mechanics and how in-socket mechanics affect patient-reported comfort and function. The objectives of this study are (1) to gain a better understanding of how in-socket mechanics of the residual limb in transfemoral amputees are related to patient-reported comfort and function, (2) to identify clinical tests that can streamline the socket design process, and (3) to evaluate the efficacy and cost of a novel, quantitatively informed socket optimization process. METHODS: Users of transfemoral prostheses will be asked to walk on a treadmill wearing their current socket plus 8 different check sockets with designed changes in different structural measurements that are likely to induce changes in residual limb motion, skin strain, and pressure distribution within the socket. Dynamic biplane radiography and pressure sensors will be used to measure in-socket residual limb mechanics. Patient-reported outcomes will also be collected after wearing each socket. The effects of in-socket mechanics on both physical function and patient-reported outcomes (aim 1) will be assessed using a generalized linear model. Partial correlation analysis will be used to examine the association between research-grade measurements and readily available clinical measurements (aim 2). In order to compare the new quantitative design method to the standard of care, patient-reported outcomes and cost will be compared between the two methods, utilizing the Wilcoxon-Mann-Whitney non-parametric test (aim 3). DISCUSSION: Knowledge on how prosthetic socket modifications affect residual bone and skin biomechanics itself can be applied to devise future socket designs, and the methodology can be used to investigate and improve such designs, past and present. Apart from saving time and costs, this may result in better prosthetic socket fit for a large patient population, thus increasing their mobility, participation, and overall health-related quality of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT05041998 . Date of registration: Sept 13, 2021.

The Mental and Physical Health of Mothers of Children with Special Health Care Needs in the United States.

OBJECTIVE: To determine the prevalence of poor mental and physical health among mothers of children with special health care needs (CSHCN) and to determine the association between maternal health and the child's number of special health care needs (SHCN) and severity of ability limitation. METHODS: We used the combined 2016-2018 National Survey of Children's Health Dataset of 102,341 children ages 0-17 including 23,280 CSHCN. We used regression models to examine the associations of a child's number of SHCN and ability limitations with maternal health. RESULTS: Twice as many mothers of CSHCN had poor mental and physical health compared to non-CSHCN (mental 10.3% vs. 4.0%, p < .001; physical 11.9% vs 5.0%, p < .001). In regression models, increased number of SHCN and severity of activity limitations were associated with significantly increased odds of poor maternal health. CONCLUSIONS FOR PRACTICE: Mothers of CSHCN have worse health compared to mothers of non-CSHCN, especially those who experience social disadvantage and those with children with complex SHCN or severe ability limitations. Interventions to improve the health of these particularly vulnerable caregivers of CSHCN are warranted.

Does socket liner material affect clinical outcomes in lower limb prosthesis users? Insights from a randomized control trial.

Among the noted disadvantages of prosthesis suspension by flexible liner is the increased rate of perspiration within the socket, which has the potential to cause discomfort, suspension issues, and tissue damage. In recent years, phase change material technology has been adopted for the use in prosthesis liners. These promise to improve temperature control and, consequently, reduce sweating. Previous work has demonstrated that this approach is effective in slowing the temperature increase at the limb-socket interface, but it was not clear how this would translate to clinical outcomes. This study had the aim to compare conventional and phase change material liners regarding prosthesis utilization, physical performance, and patient-reported outcome measures. A randomized double-blind cross-over study design with 6-month intervention periods was used. Of the 42 enrolled participants, only 50% completed the protocol. The high attrition was in large part because of the COVID-19 pandemic that started disrupting daily life and thereby the data collection midway through the study period. The findings indicate that the temperature control liners were, by trend, associated with better prosthesis utilization. The found effects did not reach the level of statistical significance, which is likely a result of the unduly reduced sample size.

Effectiveness of Group Wheelchair Maintenance Training for People with Spinal Cord Injury: A Randomized Controlled Trial.

OBJECTIVE: To assess the effectiveness of group wheelchair maintenance training and investigate participant characteristics associated with responsiveness to training. DESIGN: Randomized controlled trial with an immediate group and a waitlist control group (WLCG) who received the intervention after a 6-month delay. SETTING: Four Spinal Cord Injury Model Systems Centers. PARTICIPANTS: Manual (MWC; n=80) and power wheelchair (PWC; n=67) users with spinal cord injury (N=147). INTERVENTIONS: Two 90-minute structured wheelchair maintenance training program classes with 12-20 people per class and separate classes for MWC and PWC users. Each class included in-person hands-on demonstrations and practice of wheelchair maintenance. MAIN OUTCOME MEASURES: Separate analysis was completed for MWC and PWC users using the Wheelchair Maintenance Training Questionnaire (WMT-Q) capacity (ability to complete), performance (frequency of completion) and knowledge at baseline, 1 month, 6 months, 6 months pretraining (WLCG only), and 1 year (immediate only). RESULTS: After the intervention, participants in both the immediate and WLCG improved in maintenance capacity (MWC and PWC, P<.001) and performance (MWC and PWC, P<.001) with training. Only PWC users improved knowledge of wheelchair maintenance (P<.001). For both WLCGs (MWC and PWC), there was no difference between the 6-month pretraining time point and baseline. MWC users who responded to training had lower WMT-Q scores for all domains, whereas this was only the case for knowledge for PWC users. CONCLUSIONS: Group wheelchair skills training is effective at improving capacity to complete maintenance and performance of maintenance activities for MWC and PWC users, even in a cohort of experienced wheelchair users. For MWC users, improvements were tied to lower WMT-Q scores at baseline, whereas PWC users improved in capacity and performance independent of baseline score. Delivering this training in a structured group format has a lower cost, which might improve adoption into clinical practice.

Changes in Internet Use Over Time Among Individuals with Traumatic Spinal Cord Injury.

OBJECTIVE: To investigate the changes in total internet and mobile internet use over time and determine how demographic characteristics are related to changes in internet and mobile internet use among individuals with spinal cord injury (SCI). DESIGN: Cross-sectional analysis of a multicenter cohort study. SETTING: National SCI Database. PARTICIPANTS: Individuals with traumatic SCI with follow-up data collected between 2012 and 2018 (N=13,622). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Proportion of sample reporting internet use at all or through a mobile device over time and specifically in 2018. RESULTS: The proportion of internet users increased from 77.7% in 2012 to 88.1% in 2018. Older participants (P<.001); those with lower annual income (P<.001), less education (P<.001), non-White race or Hispanic ethnicity (P<.001), or motor incomplete tetraplegia (P=.004); and men (P=.035) were less likely to use the internet from 2012-2018. By 2018, there were no longer differences in internet use based on race and ethnicity (P=.290) or sex (P=.066). Mobile internet use increased each year (52.4% to 87.7% of internet users from 2012-2018), with a participant being 13.7 times more likely to use mobile internet in 2018 than 2012. Older age (P<.001), income <$50,000 (P<.001), high school diploma or less (P=.011), or non-Hispanic White race/ethnicity (P=.001) were associated with less mobile internet use over time. By 2018, there were no differences in mobile internet use by education (P=.430), and only participants with incomes >$75,000 per year had greater odds of mobile internet use (P=.016). CONCLUSIONS: Disparities associated with internet access are decreasing likely as a result of mobile device use. Increased internet access offers an important opportunity to provide educational and training materials to frequently overlooked groups of individuals with SCI.

A roadmap to reduce information inequities in disability with digital health and natural language processing.

People with disabilities disproportionately experience negative health outcomes. Purposeful analysis of information on all aspects of the experience of disability across individuals and populations can guide interventions to reduce health inequities in care and outcomes. Such an analysis requires more holistic information on individual function, precursors and predictors, and environmental and personal factors than is systematically collected in current practice. We identify 3 key information barriers to more equitable information: (1) a lack of information on contextual factors that affect a person's experience of function; (2) underemphasis of the patient's voice, perspective, and goals in the electronic health record; and (3) a lack of standardized locations in the electronic health record to record observations of function and context. Through analysis of rehabilitation data, we have identified ways to mitigate these barriers through the development of digital health technologies to better capture and analyze information about the experience of function. We propose 3 directions for future research on using digital health technologies, particularly natural language processing (NLP), to facilitate capturing a more holistic picture of a patient's unique experience: (1) analyzing existing information on function in free text documentation; (2) developing new NLP-driven methods to collect information on contextual factors; and (3) collecting and analyzing patient-reported descriptions of personal perceptions and goals. Multidisciplinary collaboration between rehabilitation experts and data scientists to advance these research directions will yield practical technologies to help reduce inequities and improve care for all populations.

Toward Improving the Prediction of Functional Ambulation After Spinal Cord Injury Through the Inclusion of Limb Accelerations During Sleep and Personal Factors.

OBJECTIVE: To determine if functional measures of ambulation can be accurately classified using clinical measures; demographics; personal, psychosocial, and environmental factors; and limb accelerations (LAs) obtained during sleep among individuals with chronic, motor incomplete spinal cord injury (SCI) in an effort to guide future, longitudinal predictions models. DESIGN: Cross-sectional, 1-5 days of data collection. SETTING: Community-based data collection. PARTICIPANTS: Adults with chronic (>1 year), motor incomplete SCI (N=27). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ambulatory ability based on the 10-m walk test (10MWT) or 6-minute walk test (6MWT) categorized as nonambulatory, household ambulator (0.01-0.44 m/s, 1-204 m), or community ambulator (>0.44 m/s, >204 m). A random forest model classified ambulatory ability using input features including clinical measures of strength, sensation, and spasticity; demographics; personal, psychosocial, and environmental factors including pain, environmental factors, health, social support, self-efficacy, resilience, and sleep quality; and LAs measured during sleep. Machine learning methods were used explicitly to avoid overfitting and minimize the possibility of biased results. RESULTS: The combination of LA, clinical, and demographic features resulted in the highest classification accuracies for both functional ambulation outcomes (10MWT=70.4%, 6MWT=81.5%). Adding LAs, personal, psychosocial, and environmental factors, or both increased the accuracy of classification compared with the clinical/demographic features alone. Clinical measures of strength and sensation (especially knee flexion strength), LA measures of movement smoothness, and presence of pain and comorbidities were among the most important features selected for the models. CONCLUSIONS: The addition of LA and personal, psychosocial, and environmental features increased functional ambulation classification accuracy in a population with incomplete SCI for whom improved prognosis for mobility outcomes is needed. These findings provide support for future longitudinal studies that use LA; personal, psychosocial, and environmental factors; and advanced analyses to improve clinical prediction rules for functional mobility outcomes.

Factors Associated With Ambulation and Transfer Ability: A Study From the National Spina Bifida Patient Registry.

OBJECTIVES: This study used a spina bifida electronic medical record and the National Spina Bifida Patient Registry to explore the relationship between neurosurgical/orthopedic surgeries and other variables on ambulation and transfer ability over time in individuals with spina bifida. DESIGN: This study was an analysis of longitudinal data collected within the National Spina Bifida Patient Registry and spina bifida electronic medical record. Logistic regression models were used to determine which variables were associated with ambulation/transfer ability in the myelomeningocele (MMC) and non-MMC populations. RESULTS: Longitudinal data from 806 individuals were collected. In the MMC group, decreased ambulation ability was associated with higher motor levels, tethered cord releases, spine/scoliosis surgeries, hip orthopedic surgeries, and having supplemental insurance. Increased ambulatory ability was associated with lower motor levels, tibial torsion/related surgeries, ankle/foot surgeries, being female, and being non-Hispanic/Latinx. Decreased transfer ability was associated with being Hispanic/Latinx and having higher motor levels. Lower motor level and ankle/foot surgeries were associated with increased transfer ability. No significant associations were found in the non-MMC group. CONCLUSIONS: Motor level is an important predictor of ambulation and transfer ability in MMC. Surgeries distal to the knee were associated with higher levels of function; surgeries proximal to the knee were associated with lower functional levels.

Perturbation of cortical activity elicits regional and age-dependent effects on unconstrained reaching behavior: a pilot study.

Contributions from premotor and supplementary motor areas to reaching behavior in aging humans are not well understood. The objective of these experiments was to examine effects of perturbations to specific cortical areas on the control of unconstrained reaches against gravity by younger and older adults. Double-pulse transcranial magnetic stimulation (TMS) was applied to scalp locations targeting primary motor cortex (M1), dorsal premotor area (PMA), supplementary motor area (SMA), or dorsolateral prefrontal cortex (DLPFC). Stimulation was intended to perturb ongoing activity in the targeted cortical region before or after a visual cue to initiate moderately paced reaches to one of three vertical target locations. Regional effects were observed in movement amplitude both early and late in the reach. Perturbation of PMA increased reach distance before the time of peak velocity to a greater extent than all other regions. Reaches showed greater deviation from a straight-line path around the time of peak velocity and greater overall curvature with perturbation of PMA and M1 relative to SMA and DLPFC. The perturbation increased positional variability of the reach path at the time of peak velocity and the time elapsing after peak velocity. Although perturbations had stronger effects on reaches by younger subjects, this group exhibited less reach path variability at the time of peak velocity and required less time to adjust the movement trajectory thereafter. These findings support the role of PMA in visually guided reaching and suggest an age-related change in sensorimotor processing, possibly due to a loss of cortical inhibitory control.

Effect of the Assistive Technology Professional on the Provision of Mobility Assistive Equipment.

OBJECTIVE: The purpose of this study was to examine factors associated with variability in satisfaction with functional mobility (as measured by the Functional Mobility Assessment [FMA]) in users of mobility devices. Our primary hypothesis was that device type and Assistive Technology Professional (ATP) involvement will be the most significant predictors of FMA score. Our secondary hypothesis was that ATP involvement is associated with use of more custom-fitted manual wheelchairs and group 3 and 4 power wheelchairs. DESIGN: Retrospective cohort study. SETTING: Data were collected from equipment suppliers who collaborate with clinicians to administer the FMA and associated Uniform Data Set within various settings (ie, rehabilitation clinic, school, supplier place of business). PARTICIPANTS: A data set of 4743 cases was included in the analysis (N=4743). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FMA questionnaire collected at baseline, client age, gender, primary diagnosis, years since disability onset, device type, device age, living situation, ATP involvement, and geographic area. RESULTS: Ordinal logistic regression modeling showed that geographic area, device type, ATP involvement, primary diagnosis, gender, age, device age, and years since onset of disability significantly predicted the variance in FMA scores at P<.05. Device type was the most significant predictor of variance in FMA score. Involvement of an ATP had a significant effect on the type of device that participants used (χ220=1739.18, P<.001; odds ratio, 0.589; 95% confidence interval, 0.49-0.708). If an ATP was involved, there were significantly higher proportions (all P<.05) of individuals using custom-fitted manual wheelchair and high-end groups 3 and 4 power wheelchairs prescribed compared with when no ATP was involved or when involvement was uncertain. CONCLUSIONS: The relationship between ATP involvement and functional outcome supports the concept that ATP certification recognizes demonstrated competence in analyzing the needs of consumers with disabilities and selection of appropriate mobility assistive equipment with improved functional outcomes.

Treelet transform analysis to identify clusters of systemic inflammatory variance in a population with moderate-to-severe traumatic brain injury.

BACKGROUND: Inflammatory cascades following traumatic brain injury (TBI) can have both beneficial and detrimental effects on recovery. Single biomarker studies do not adequately reflect the major arms of immunity and their relationships to long-term outcomes. Thus, we applied treelet transform (TT) analysis to identify clusters of interrelated inflammatory markers reflecting major components of systemic immune function for which substantial variation exists among individuals with moderate-to-severe TBI. METHODS: Serial blood samples from 221 adults with moderate-to-severe TBI were collected over 1-6 months post-injury (n = 607 samples). Samples were assayed for 33 inflammatory markers using Millipore multiplex technology. TT was applied to standardized mean biomarker values generated to identify latent patterns of correlated markers. Treelet clusters (TC) were characterized by biomarkers related to adaptive immunity (TC1), innate immunity (TC2), soluble molecules (TC3), allergy immunity (TC4), and chemokines (TC5). For each TC, a score was generated as the linear combination of standardized biomarker concentrations and cluster load for each individual in the cohort. Ordinal logistic or linear regression was used to test associations between TC scores and 6- and 12-month Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS), and covariates. RESULTS: When adjusting for clinical covariates, TC5 was significantly associated with 6-month GOS (odds ratio, OR = 1.44; p-value, p = 0.025) and 6-month DRS scores (OR = 1.46; p = 0.013). TC5 relationships were attenuated when including all TC scores in the model (GOS: OR = 1.29, p = 0.163; DRS: OR = 1.33, p = 0.100). When adjusting for all TC scores and covariates, only TC3 was associated with 6- and 12-month GOS (OR = 1.32, p = 0.041; OR = 1.39, p = 0.002) and also 6- and 12-month DRS (OR = 1.38, p = 0.016; OR = 1.58, p = 0.0002). When applying TT to inflammation markers significantly associated with 6-month GOS, multivariate modeling confirmed that TC3 remained significantly associated with GOS. Biomarker cluster membership remained consistent between the GOS-specific dendrogram and overall dendrogram. CONCLUSIONS: TT effectively characterized chronic, systemic immunity among a cohort of individuals with moderate-to-severe TBI. We posit that chronic chemokine levels are effector molecules propagating cellular immune dysfunction, while chronic soluble receptors are inflammatory damage readouts perpetuated, in part, by persistent dysfunctional cellular immunity to impact neuro-recovery.

Identifying Children With Medical Complexity From the National Survey of Children's Health Combined 2016-17 Data Set.

OBJECTIVES: To develop a method of identifying children with medical complexity (CMC) from the National Survey of Children's Health (NSCH) 2016-2017 combined data set, to compare this approach to existing CMC identification strategies, and to describe sociodemographic characteristics of our CMC sample. METHODS: Using survey items pertinent to the medical complexity domains in the style by Cohen et al (chronic health conditions, health service needs, health care use, and functional limitations), we created a schema to categorize children as CMC by applying a 95th percentile cutoff for survey item positivity. We applied existing CMC identification techniques to the NSCH. We used 2-proportion z tests to compare the classification output of our CMC identification method to those of existing approaches. We used χ2 analyses to examine relationships between child and family characteristics, comparing CMC with children with special health care needs (CSHCN) and children with no special health care needs. RESULTS: Among the 71 811 children in the sample, 1.5% were classified as CMC by our method, representing almost 1.2 million children (weighted) in the United States in 2016-2017. CSHCN and children with no special health care needs represented 17.2% (weighted n = 12.6 million) and 81.2% (weighted n = 59.6 million) of the sample, respectively. Our approach classified a significantly smaller number of CSHCN as CMC than existing CMC identification methods, which classified 3.9% to 13.2% of the 2016-2017 NSCH sample as more complex (P < .001). CMC status was significantly associated with male sex, minority race or ethnicity, and experiencing socioeconomic adversity (all P < .001). CONCLUSIONS: This method enables standardized identification of CMC from NSCH data sets, thus allowing for an examination of CMC health outcomes, pertinent to pediatric hospitalist medicine, contained in the survey.

Most Children With Medical Complexity Do Not Receive Care in Well-Functioning Health Care Systems.

OBJECTIVES: To describe the access of children with medical complexity (CMC) to well-functioning health care systems. To examine the relationships between medical complexity status and this outcome and its component indicators. PATIENTS AND METHODS: Secondary analysis of children in the National Survey of Children's Health combined 2016-2017 data set who received care in well-functioning health systems. Secondary outcomes included this measure's component indicators. The χ2 analyses were used to examine associations between child and family characteristics and the primary outcome. Adjusted multivariable logistic regression was used to examine relationships between medical complexity status and primary and secondary outcomes. Using these regression models, we examined the interaction between medical complexity status and household income. RESULTS: CMC accounted for 1.6% of the weighted sample (n = 1.2 million children). Few CMC (7.6%) received care in a well-functioning health care system. CMC were significantly less likely than children with special health care needs (CSHCN) (odds ratio, 0.3) of meeting criteria for this primary outcome. Attainment rates for secondary outcomes (families feeling like partners in care; receives care within a medical home; received needed health care) were significantly lower among CMC than CSHCN. Family income was significantly associated with likelihood of meeting criteria for primary and secondary outcomes; however, the relationships between medical complexity status and our outcomes did not differ by income level. CONCLUSIONS: CMC are less likely than other CSHCN to report receiving care in well-functioning health care systems at all income levels. Further efforts are necessary to better adapt current health care systems to meet the unique needs of CMC.

Sensory restoration by epidural stimulation of the lateral spinal cord in upper-limb amputees.

Restoring somatosensory feedback to people with limb amputations is crucial to improve prosthetic control. Multiple studies have demonstrated that peripheral nerve stimulation and targeted reinnervation can provide somatotopically relevant sensory feedback. While effective, the surgical procedures required for these techniques remain a major barrier to translatability. Here, we demonstrate in four people with upper-limb amputation that epidural spinal cord stimulation (SCS), a common clinical technique to treat pain, evoked somatosensory percepts that were perceived as emanating from the missing arm and hand. Over up to 29 days, stimulation evoked sensory percepts in consistent locations in the missing hand regardless of time since amputation or level of amputation. Evoked sensations were occasionally described as naturalistic (e.g. touch or pressure), but were often paresthesias. Increasing stimulus amplitude increased the perceived intensity linearly, without increasing area of the sensations. These results demonstrate the potential of SCS as a tool to restore somatosensation after amputations.

Even some of the most advanced prosthetic arms lack an important feature: the ability to relay information about touch or pressure to the wearer. In fact, many people prefer to use simpler prostheses whose cables and harnesses pass on information about tension. However, recent studies suggest that electrical stimulation might give prosthesis users more sensation and better control. After an amputation, the nerves that used to deliver sensory information from the hand still exist above the injury. Stimulating these nerves can help to recreate sensations in the missing limb and improve the control of the prosthesis. Still, this stimulation requires complicated surgical interventions to implant electrodes in or around the nerves. Spinal cord stimulation ­ a technique where a small electrical device is inserted near the spinal cord to stimulate nerves ­ may be an easier alternative. This approach only requires a simple outpatient procedure, and it is routinely used to treat chronic pain conditions. Now, Chandrasekaran, Nanivadekar et al. show that spinal cord stimulation can produce the feeling of sensations in a person's missing hand or arm. In the experiments, four people who had an arm amputation underwent spinal cord stimulation over 29 days. During the stimulation, the participants reported feeling electrical buzzing, vibration, or pressure in their missing limb. Changing the strength of the electric signals delivered to the spinal cord altered the intensity of these sensations. The experiments are a step toward developing better prosthetics that restore some sensation. Further studies are now needed to determine whether spinal cord stimulation would allow people to perform sensory tasks with a prosthetic, for example handling an object that they cannot see.