Bladder and bowel function effects on emotional functioning in youth with spinal cord injury: a serial multiple mediator analysis.

STUDY DESIGN: Preliminary explanatory or mechanistic cross-sectional study. OBJECTIVES: This preliminary cross-sectional study investigates the hypothesized serial mediating effects of bladder/bowel worry, social worry, and social participation in the relationship between bladder function or bowel function and emotional functioning in youth with spinal cord injury (SCI) from their perspective. METHODS: The Bladder Function, Bowel Function, Worry Bladder Bowel, Worry Social, and Social Participation Scales from the PedsQL™ Spinal Cord Injury Module and the Emotional Functioning Scale from the PedsQL™ 4.0 Generic Core Scales Short Form SF15 were completed by 127 youth with SCI ages 8-24. Serial multiple mediator model analyses were conducted to test the hypothesized sequential mediating effects of bladder/bowel worry, social worry, and social participation as intervening variables separately for the cross-sectional association between bladder function or bowel function and emotional functioning. RESULTS: The separate cross-sectional negative association of bladder function and bowel function with emotional functioning were serially mediated by bladder/bowel worry, social worry and social participation, accounting for 28% and 31%, respectively, of the variance in youth-reported emotional functioning (p < 0.001), representing large effect sizes. CONCLUSIONS: In this preliminary study, bladder/bowel worry, social worry, and social participation explain in part the cross-sectional negative association of bladder function and bowel function with emotional functioning in youth with SCI from the youth perspective. Identifying the hypothesized associations of bladder function and bowel function, bladder/bowel worry, social worry, and social participation with emotional functioning may help inform future clinical research and practice for youth with SCI.

Development of the Pediatric Quality of Life Inventory™ Spinal Cord Injury (PedsQL™ SCI) module: qualitative methods.

STUDY DESIGN: It is a qualitative study. OBJECTIVES: To develop the items and support content validity for the Pediatric Quality of Life Inventory™ (PedsQL™) Spinal Cord Injury Module for youth and emerging adults with spinal cord injury (SCI). SETTING: Community and children's hospital. METHODS: A comprehensive literature review was conducted in pediatric and SCI-specific health-related quality-of-life (HRQoL) measures to create an item bank. A multidisciplinary panel of experts convened to discuss the conceptual framework of the module, reviewed the item bank, and generated a core set of items through a process of "binning-and-winnowing". International clinicians and researchers participated in iterative rounds of a Modified Delphi survey, until 90% agreement was reached on all items of the core set, resulting in the construction of a preliminary module. Cognitive interviews were conducted on individuals with SCI and their parents to determine the relevance of items and age-appropriate wording of the preliminary module. The research team regularly reviewed transcriptions of the interviews, and incorporated participant feedback to modify the modules. This process was repeated until content saturation was achieved. RESULTS: A total of 43 participants completed the cognitive interviews. Following five iterations of cognitive interviews and modifications based on participant input, the PedsQL™ SCI Module was generated. It comprised 67 items in the 12 domains of Daily Activities, Mobility, Bladder Function, Bowel Function, Muscle Spasms, Pressure Injury, Pain, Orthostatic Hypotension, Autonomic Dysreflexia, Participation, Worry, and Emotions. CONCLUSIONS: The PedsQL™ SCI Module was developed using well-established qualitative methods. Internet-based field testing is underway to finalize its development and validation.

Long-Term Outcomes and Longitudinal Changes of Neurogenic Bowel Management in Adults With Pediatric-Onset Spinal Cord Injury.

OBJECTIVES: To describe long-term outcomes of neurogenic bowel dysfunction (NBD), determine changes over time in the type of bowel program, and determine changes in psychosocial outcomes associated with NBD-related factors in adults with pediatric-onset spinal cord injury (SCI). DESIGN: Longitudinal cohort survey. Follow-up occurred annually for a total of 466 interviews, with most participants (75%) contributing to at least 3 consecutive interviews. SETTING: Community. PARTICIPANTS: Adults (N=131) who had sustained an SCI before the age of 19 years (men, 64.1%; tetraplegia, 58.8%; mean age ± SD, 33.4±6.1y; mean time since injury ± SD, 19.5±7.0y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Type and evacuation time of bowel management programs; standardized measures assessing life satisfaction, health perception, depressive symptoms, and participation. Generalized estimating equations were formulated to determine odds of change in outcomes over time. RESULTS: At first interview, rectal suppository/enema use was most common (51%). Over time, the likelihood of using manual evacuation (odds ratio [OR]=1.077; 95% confidence interval [CI], 1.023-1.134; P=.005), oral laxatives (OR=1.052; 95% CI, 1.001-1.107; P=.047), and colostomy (OR=1.071; 95% CI, 1.001-1.147; P=.047) increased, whereas the odds of rectal suppository use decreased (OR=.933; 95% CI, .896-.973; P=.001). Bowel evacuation times were likely to decrease over time in participants using manual evacuation (OR=.499; 95% CI, .256-.974; P=.042) and digital rectal stimulation (OR=.490; 95% CI, .274-.881; P=.017), but increase for rectal suppository/enema use (OR=1.871; 95% CI, 1.264-2.771; P=.002). When the level of injury was controlled for, participants using manual evacuation and digital rectal stimulation were more likely to have increases in community participation scores (P<.05). CONCLUSIONS: Changes in type of bowel program over time may be associated with the time required to complete bowel evacuation in this relatively young adult SCI population.

Occupational characteristics of adults with pediatric-onset spinal cord injury.

BACKGROUND: Employment rates among individuals with spinal cord injury (SCI) are lower than in the general population and little is known about the specific occupations in which they are employed. OBJECTIVES: To describe specific occupations of adults with pediatric-onset SCI using the 2010 Standard Occupational Classification (SOC) system and to determine associations between SOC occupations and demographic factors. METHODS: Cross-sectional data specific to education and employment were collected from the last interviews of a larger longitudinal study. Occupations were categorized according to the 2010 SOC system. SOC groups were compared within gender level of injury and final education. RESULTS: Of the 461 total participants 219 (47.5%) were employed and specific occupations were available for 179. Among the SOC groups Education Law Community Service Arts and Media Occupations were most prevalent (30.2%) followed by Management Business and Finance Occupations (21.1%) Computer Engineering and Science Occupations (10.6%) Administrative and Office Support Occupations (10.0%) Service Occupations (7.3%) Healthcare Practitioners and Technical Occupations (3.9%) and Production Occupations (3.4%). Differences were found in the distribution of SOC groups between gender levels of injury and final education groups. CONCLUSION: A wide variety of occupations were reported in adults with pediatric-onset SCI generally in concordance with final education and functional ability levels.

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

OBJECTIVES: To determine longitudinal changes in the occurrence of medical complications in adults with pediatric-onset spinal cord injury (SCI). DESIGN: Longitudinal study of long-term outcomes. SETTING: Community. PARTICIPANTS: Individuals who had sustained an SCI before age 19, were 23 years of age or older at initial interview, and followed annually between 1996 and 2011. They were classified into four American Spinal Injury Association (ASIA) Impairment Scale (AIS) severity groups: C1-4 AIS ABC, C5-8 AIS ABC, T1-S5 AIS ABC, AIS D. OUTCOME MEASURES: Generalized estimating equation (GEE) models were formulated to obtain the odds ratio (OR) of having a medical complication over time. RESULTS: A total of 1793 interviews were conducted among 226 men and 125 women (86% Caucasian; age at baseline, 26.7 ± 3.6 years; time since injury at baseline, 12.9 ± 5.2 years). Odds of complication occurrence over time varied among severity groups, with increased ORs of severe urinary tract infection (1.05, confidence interval (CI) 1.02-1.09), autonomic dysreflexia (AD) (1.09, CI 1.05-1.14), spasticity (1.06, CI 1.01-1.11), pneumonia/respiratory failure (1.09, CI 1.03-1.16), and hypertension/cardiac disease (1.07, CI 1.01-1.15) in the C1-4 ABC group; AD (1.08, CI 1.04-1.13) and pneumonia/respiratory failure (1.09, CI 1.02-1.16) in the C5-8 ABC group; and hypertension/cardiac disease (1.08, CI 1.02-1.14) in the T1-S5 ABC group. Upper extremity joint pain had increased odds of occurrence in all injury severity groups. CONCLUSION: The significantly increased odds of having medical complications over time warrants awareness of risk factors and implementation of preventive measures to avoid adverse consequences of complications and to maintain independence in individuals with pediatric-onset SCI.

Normative blood pressure and heart rate in pediatric spinal cord injury.

BACKGROUND: Cardiovascular measures in children with spinal cord injury (SCI) may vary depending on the child's age and physical development in addition to injury-related factors. Developmental changes should be considered when addressing cardiovascular complications in this population. OBJECTIVES: To determine baseline blood pressure (BP) and heart rate (HR) measurements in youth with SCI, and to investigate differences in BP and HR in relation to age, gender, body mass index (BMI), and injury-related factors. METHODS: Retrospective chart review was conducted for youth under 19 years who had been admitted for rehabilitation at 1 of 2 pediatric SCI programs. Systolic (SBP) and diastolic (DBP) blood pressures and HR were collected in the morning and afternoon on 3 consecutive days. Mean SBP, DBP, and HR were compared among 4 age groups (0-5 years, 6-12 years, 13-15 years, and 16-18 years) and by gender. Diurnal variations were determined according to level and severity of injury. Associations with BMI and injury-related factors were examined. Charts of 315 youths were reviewed: mean age was 12.3 years, 59% were male, 75% were Caucasian, 62% had complete injury, and 66% had paraplegia. RESULTS: With increasing age, SBP and DBP increased and HR decreased. SBP and DBP were positively correlated with BMI. SBP was higher in males, those with incomplete injury, and those with paraplegia. HR was higher in females. There was no association between cardiovascular measures and injury duration. CONCLUSION: BP and HR are a function of age, BMI, and completeness and level of injury in youth with SCI. Awareness of baseline measures will allow for more effective management of cardiovascular complications, especially in youth presenting with atypical symptoms.

A Systematic Review of High-Dose Methotrexate for Adults with Primary Central Nervous System Lymphoma.

Primary central nervous system lymphoma (PCNSL) is a highly aggressive non-Hodgkin lymphoma that is confined within the CNS. Due to its ability to cross the blood-brain barrier, high-dose methotrexate (HDMTX) is the backbone for induction chemotherapy. This systematic review was conducted to observe outcomes among different HDMTX doses (low, <3 g/m2; intermediate, 3-4.9 g/m2; high, ≥5 g/m2) and regimens used in the treatment of PCNSL. A PubMed search resulted in 26 articles reporting clinical trials using HDMTX for PCNSL, from which 35 treatment cohorts were identified for analysis. The median dose of HDMTX used for induction was 3.5 g/m2 (interquartile range IQR, 3-3.5); the intermediate dose was most frequently used in the studies examined (24 cohorts, 69%). Five cohorts used HDMTX monotherapy, 19 cohorts used HDMTX + polychemotherapy, and 11 cohorts used HDMTX + rituximab ± polychemotherapy. Pooled overall response rate (ORR) estimates for low, intermediate, and high dose HDMTX cohorts were 71%, 76%, and 76%, respectively. Pooled 2-year progression-free survival (PFS) estimates for low, intermediate, and high HDMTX dose cohorts were 50%, 51%, and 55%, respectively. Regimens that included rituximab showed a tendency to have higher ORR and 2-year PFS than those that did not include rituximab. These findings indicate that current protocols utilizing 3-4 g/m2 of HDMTX in combination with rituximab provide therapeutic efficacy in PCNSL.

PedsQL™ Spinal Cord Injury Module: Reliability and Validity.

OBJECTIVES: The objective was to report on the initial measurement properties of the Pediatric Quality of Life Inventory™ (PedsQL™) Spinal Cord Injury (SCI) Module in youth with SCI from the youth and parent perspectives. METHODS: PedsQL™ SCI Module and PedsQL™ 4.0 Generic Core Scales SF15 were completed in a multisite national study by 166 youth ages 8 to 25 years and 128 parents of youth ages 5 to 23 years. Data from the PedsQL™ Generic Core Scales were compared with an age- and sex-matched healthy control sample. Factor analysis was conducted to determine the factor structure of the items. RESULTS: In addition to a Total Scale Score, nine unidimensional scales were derived measuring daily activities, mobility, bladder function, bowel function, pressure injury, pain interference, social participation, worry bladder bowel, and worry social. The PedsQL™ SCI Module evidenced excellent reliability for Total Scale Scores (youth self-report, α = 0.93; parent proxy-report, α = 0.93) and acceptable reliability for the nine individual scales (youth self-report, α = 0.71-0.83; parent proxy-report, α = 0.67-0.87). Intercorrelations with the Generic Core Scales supported construct validity with medium to large effect sizes (most ps < .001). Factor analysis supported the unidimensionality of the nine individual scales. PedsQL™ Generic Core Scales comparisons to healthy controls demonstrated significantly impaired generic health-related quality of life in youth with SCI with large effect sizes. CONCLUSION: The PedsQL™ SCI Module Scales demonstrated acceptable measurement properties and may be utilized as standardized scales to assess SCI-specific concerns and problems in clinical research and practice in youth with SCI.

Pain, pain interference, social and school/work functioning in youth with spinal cord injury: A mediation analysis.

Context/Objective: The objective of the present study was to investigate the effects of pain severity, pain interference and social functioning in a serial multiple mediator model predicting school/work functioning in youth with spinal cord injury (SCI) from their perspective.Design: Explanatory or mechanistic study.Setting: Pediatric specialty hospital.Participants: 125 youth with SCI ages 8-24.Outcome Measures: The Pain Severity Item and Pain Interference Scale from the PedsQL™ Spinal Cord Injury Module, and the Social Functioning and School/Work Functioning Scales from the PedsQL™ 4.0 Generic Core Scales Short Form SF15 were completed.Results: Hierarchical multiple regression and serial multiple mediator model analyses were conducted to test the percent variability accounted for and the mediating effects of pain interference and social functioning in the association between pain severity and school/work functioning. Pain predictive effects on school/work functioning were serially mediated by pain interference and social functioning. In a predictive analytics model conducted with hierarchical multiple regression analysis, age, sex, pain, pain interference and social functioning accounted for 45% of the variance in youth-reported school/work functioning (P < 0.001), demonstrating a large effect size.Conclusion: The mechanisms of the predictive effects of pain severity on school/work functioning in youth with SCI are explained in part by the serial multiple mediator effects of pain interference and social functioning. Identifying the multiple mediators of SCI pain on school/work functioning from the perspective of youth with SCI may facilitate future clinical research and practice to ameliorate impaired daily functioning and improve overall well-being.

Gait Characteristics in Youth With Transverse Myelitis.

BACKGROUND: Transverse myelitis (TM) in childhood is a rare disorder characterized by the presence of spinal cord inflammation. Gait difficulty in children with TM is common; however, there is a paucity of literature regarding quantitative assessment of gait in children and adolescents with TM. OBJECTIVES: To characterize gait patterns in a cohort of ambulatory children with TM and age-matched, typically developing peers in order to better understand the functional mobility of patients diagnosed with childhood TM. METHODS: This was a retrospective study of 26 ambulatory pediatric patients with a confirmed diagnosis of TM who had undergone three-dimensional, instrumented gait analysis (3D-IGA) at 3 years of age or older. A group of 38 typically developing children served as a control group. RESULTS: Gait in children with TM was characterized by moderate kinematic deviations as measured by the Gait Deviation Index (GDI) and a crouched gait pattern (p < .001), increased anterior pelvic tilt (p < .001), decreased motion at the knees (p < .001), and a wider base of support (foot progression angle, p < .001). The TM group had a slower walking speed (p < .001), shorter strides (p < .001), and an increased stance phase compared to controls. CONCLUSION: Our study results showed moderate kinematic deviations quantified by the GDI. Overall, the gait pattern in the TM population tested had greater hip and knee flexion with wider foot progression angle. Identification of gait characteristics in children with TM is the first step in predicting changes in gait pattern as they mature over time, which may ultimately allow for targeted intervention to maintain their ambulatory function.

Development of the International Spinal Cord Injury/Dysfunction Education Basic Data Set.

Study design: Consensus among international experts. Objectives: The objective of this project was to develop the International Spinal Cord Injury/Dysfunction (SCI/D) Education Basic Data Set. Setting: International expert working group. Methods: The published guidelines for developing the International SCI Basic Data Sets were used to develop the International SCI/D Education Basic Data Set. Existing measures and literature on education and disability were reviewed to develop a preliminary draft of the basic education data set through iterative modifications via biweekly conference calls and email communication. The draft was disseminated to the larger International Workgroup for Development of Pediatric SCI/D Basic Data Sets and then to the members of the International Spinal Cord Society (ISCoS), American Spinal Injury Association (ASIA), and relevant expert groups and interested individuals for comments. All feedback received was taken into consideration before the final data set was approved by ISCoS and ASIA. Results: The finalized version of the International SCI/D Education Basic Data Set Version 1.0 contains 16 items divided into three domains: school setting/therapeutic services, school participation/academic success, and barriers/attitudes. Most of the variables have been adapted from established measures. This data set is intended for children and youth up to and including high school, but not for emerging adults in higher education or postsecondary vocational training or trade schools. Conclusion: The International SCI/D Education Basic Data Set has been developed for collection of a minimal amount of highly relevant information on the education experience in children and youth with SCI/D. Further validation work is needed. Sponsorship: This project was funded by the Rick Hansen Institute, Research Award #G2015-27 (Mulcahey, PI).

The International Spinal Cord Injury Pediatric Activity and Participation Basic Data Set.

Study design: International focus groups. Objectives: The objective of this project was to develop the International Spinal Cord Injury (SCI) Pediatric Activity and Participation (A&P) Basic Data Set. Methods: A focus group of experts in pediatric and adult SCI, and contributors of the existing adult International SCI Adult A&P Basic Data Set convened to develop an initial draft of the data set, which was iteratively refined over a 12 month period based on relevant literature and existing outcome measures that evaluate pediatric activity and participation. The draft was reviewed and approved by the larger project working group and then distributed to the International Spinal Cord Society (ISCoS), American Spinal Injury Association (ASIA), and relevant expert groups for review. Feedback received was considered before the final data set was approved. Results: The International SCI Pediatric A&P Basic Data Set is comprised of 13 variables: administration date, mobility, dressing, feeding, toileting, communication, family outings, spending time with friends, being out with friends, participating in team or club activity, paid work, dating, and physical activity. It is intended for children between 6 and 17 years of age, who have been discharged from initial rehabilitation/hospitalization for a minimum of 3 months. Conclusion: The International SCI Pediatric A&P Basic Data Set was developed to standardize the recording of a minimal amount of information about activities and participation in children with SCI. Further work on reliability and cultural validation is needed. Sponsorship: This study was funded by the Rick Hansen Institute, Research Award #G2015-27 (Mulcahey, PI).

Frequency and severity of carpal tunnel syndrome according to level of cervical radiculopathy: double crush syndrome?

OBJECTIVE: The double crush hypothesis (DC) proposes that a proximal lesion along an axon predisposes it to injury at a more distal site along its course through impaired axoplasmic flow. The frequency and severity of carpal tunnel syndrome (CTS) according to the level of cervical radiculopathy were investigated to evaluate the hypothesis of DC. METHODS: The frequency of CTS was investigated in 277 patients with C6, C7 or C8 radiculopathies and correlation between CTS and radiculopathy level was determined. We also investigated whether the degrees of abnormal sensory responses were more severe in C6, C7 radiculopathies and whether motor responses were more severe in C8 radiculopathy. RESULTS: Thirty-nine patients were diagnosed with CTS and concomitant cervical radiculopathy at the C6, 7, or C8 root levels. The frequency of coexisting CTS was not statistically different according to the level of radiculopathy. The electrophysiologic results revealed no significant correlation between median sensory parameters and C6, C7 cases, and no relationship was observed between median motor responses and C8 radiculopathy. CONCLUSIONS: The frequency and electrophysiologic data of CTS analyzed according to cervical radiculopathy level do not support a neurophysiological explanation. SIGNIFICANCE: Based on this study, the DC hypothesis could not be supported.

Referred pain pattern of the pronator quadratus muscle.

Pain patterns of the myofascial trigger points (TrP) for most muscles of the forearm have been documented. However, there are no published reports on the referred pain patterns for the pronator quadratus (PQ) muscle. The purpose of this study was to determine the referred pain pattern of the TrP in the PQ. Thirty-five arms of 35 healthy adult volunteers with no history of neck pain, arm pain or paresthesia were studied. Following skin sterilization, a Teflon-coated syringe needle was inserted into the PQ of the non-dominant forearm under electromyographic guidance, and 0.3mL of 6% hypertonic saline was injected. Subjects drew in their pain areas on a pain diagram, and this drawing was transferred into the Pain Chart System for analysis. Two main pain patterns were observed. The most common pattern involved pain spreading both distally and proximally from the injection site, along the medial aspect of the forearm (57%). In half of these cases, the pain area extended to the medial epicondyle proximally and the fifth digit distally. The second main pattern revealed pain spreading distally to the third and/or fourth finger (29%). The pain patterns originating from the PQ resemble the C8-T1 dermatomes, and ulnar and median nerve sensory distributions. Thus, myofascial pain of the PQ should be considered as a possible cause of pain in the medial forearm and hand, especially when no other neurological abnormalities are present.

Reference values of fractionated neurography of the ulnar nerve at the wrist in healthy subjects.

OBJECTIVE: This study is designed to derive a normative database for nerve conduction values of the ulnar nerve in the wrist. METHODS: Ulnar nerve study at the wrist (UNSW) was performed in 204 hands of 102 control subjects. The UNSW was composed of motor and sensory tests. Motor UNSW was done with first dorsal interosseous muscle recording. Sensory UNSW was performed antidromically with fifth finger recording. The 3 stimulation points were 2 cm proximal to the pisiform, just lateral to pisiform, and 3 cm distal to the pisiform. RESULTS: Mean latency differences in the proximal and distal segments were 0.4 +/- 0.1 and 0.5 +/- 0.1 ms in motor UNSW and 0.4 +/ -0.1 and 0.5 +/- 0.1 ms in sensory UNSW. The 95th percentile values for motor and sensory UNSW were 0.5 ms in the proximal segment and 0.7 ms in the distal segment. CONCLUSIONS: When the 95-percentile value was considered as the normal upper limit, the criteria of abnormality for motor and sensory UNSW were greater than 0. 5 ms in the proximal segment and greater than 0.7 ms in the distal segment. SIGNIFICANCE: The normative values of UNSW may be useful in screening for ulnar neuropathy at the wrist.

Localization of ulnar neuropathy at the elbow using new stimulator for the inching test.

OBJECTIVE: To evaluate the usefulness of the TenElectrodes, a new stimulator for inching test, in the diagnosis and localization of ulnar neuropathy at the elbow (UNE). METHODS: Sixty-two ulnar nerves in 40 control subjects and 24 ulnar nerves in 23 patients with typical symptoms and signs of UNE were studied. The inching test of ulnar motor nerve using TenElectrodes was done along 8 cm across the elbow in the extended position. RESULTS: In the inching test of the control group, the mean segmental latency difference was 0.19+/-0.08 ms. Maximal latency difference over a 1 cm segment did not exceed 0.40 ms in any of the controls but exceeded 0.5 ms or more in all clinical UNE patients. In all UNE patients, the lesion sites were identified by the inching test using TenElectrodes: the retroepicondylar groove (54.2%), the humeroulnar arcade (29.2%), and dual compression (16.6%). CONCLUSIONS: TenElectrodes is a useful stimulator for the inching test in the diagnosis of UNE. The precise localization of compression was possible in all patients with UNE and the most common site was the retroepicondylar groove.

Tenelectrodes: a new stimulator for inching technique in the diagnosis of carpal tunnel syndrome.

This study was designed to evaluate the usefulness of a new multielectrode stimulator, TenElectrodes, in the diagnosis and localization of the compression site in the wrists of carpal tunnel syndrome (CTS) patients. Antidromic inching technique (IT) of the median nerve at the wrist was performed with the TenElectrodes, on 46 controls and 21 CTS patients. In controls, mean conduction delay per centimeter (CD/cm) was 0.21 milliseconds (ms), and maximal CD/cm was 0.27 ms in the segment 3 to 4 centimeters distal to the distal wrist crease. The abnormal cut-off value, calculated as the maximal CD/cm + 2SD, was 0.45 ms. In the CTS group, the maximal CD/cm was 0.56 ms in the segment 2 to 3 centimeters distal to the distal wrist crease, and the CD/cm values in all segments between the distal wrist crease and 4 cm distal to the distal wrist crease were greater than 0.45 ms. Antidromic IT using TenElectrodes may be an easy, fast and accurate method as the electrodes of the stimulator are aligned at 1-cm intervals and are adjustable to the wrist contour by springs.

Autonomic cardiovascular dysfunction and vitamin D deficiency in pediatric spinal cord injury.

OBJECTIVE: The purpose of this manuscript is to present a general overview and preliminary results of pilot projects of two complications in pediatric spinal cord injury (SCI): autonomic cardiovascular dysfunction and vitamin D deficiency. METHODS: Retrospective cross-sectional investigations of blood pressures (BP), heart rates (HR), and vitamin D levels were performed. RESULTS: Among 279 children with SCI, it was observed that baseline BP increases and HR decreases with increasing age. Boys had higher systolic BP and girls had higher HR, but a gender difference in diastolic BP did not emerge. There were no significant associations of baseline BP or HR as a function of injury level, severity, or duration. Among 82 youth with SCI, 79% had vitamin D deficiency or insufficiency. There were no differences in vitamin D status as a function of gender or level of injury. Adolescents, however, were more likely to exhibit deficiency compared to children. IMPLICATIONS: Because of the clinical significance of autonomic dysreflexia and orthostatic hypotension, baseline BP and HR need to be routinely assessed in youth with SCI. In view of the high prevalence of vitamin D insufficiency in youth with SCI and the risk of complications such as pathological fractures, serum 25-hydroxycholecalciferol levels should be routinely monitored.

Combined passive stretching and active movement rehabilitation of lower-limb impairments in children with cerebral palsy using a portable robot.

BACKGROUND: Ankle impairments are closely associated with functional limitations in children with cerebral palsy (CP). Passive stretching is often used to increase the range of motion (ROM) of the impaired ankle. Improving motor control is also a focus of physical therapy. However, convenient and effective ways to control passive stretching and motivate active movement training with quantitative outcomes are lacking. OBJECTIVE: To investigate the efficacy of combined passive stretching and active movement training with motivating games using a portable rehabilitation robot. METHODS: Twelve children with mild to moderate spastic CP participated in robotic rehabilitation 3 times per week for 6 weeks. Each session consisted of 20 minutes of passive stretching followed by 30 minutes of active movement training and ended with 10 minutes of passive stretching. Passive ROM (PROM), active ROM (AROM), dorsiflexor and plantarflexor muscle strength, Selective Control Assessment of the Lower Extremity, and functional outcome measures (Pediatric Balance Scale, 6-minute walk, and Timed Up-and-Go) were evaluated before and after the 6-week intervention. RESULTS: Significant increases were observed in dorsiflexion PROM (P = .002), AROM (P = .02), and dorsiflexor muscle strength (P = .001). Spasticity of the ankle musculature was significantly reduced (P = .01). Selective motor control improved significantly (P = .005). Functionally, participants showed significantly improved balance (P = .0025) and increased walking distance within 6 minutes (P = .025). CONCLUSIONS: Passive stretching combined with engaging in active movement training was of benefit in this pilot study for children with CP. They demonstrated improvements in joint biomechanical properties, motor control performance, and functional capability in balance and mobility.