Scoping Review of School-to-Work Transition for Youth With Intellectual Disabilities: A Practice Gap

IMPORTANCE

Youth with intellectual disabilities (ID) have persistently poor work outcomes. Occupational therapy can support school-to-work transition but is underrepresented in transition practice.

OBJECTIVE

To identify and describe interventions within the scope of occupational therapy for youth with ID who are transitioning from school to work.

DATA SOURCES

MEDLINE, ERIC, PsycINFO, and CINAHL were searched, and hand searching was performed in relevant peer-reviewed journals.

STUDY SELECTION AND DATA COLLECTION

Included were peer-reviewed, English-language articles published from 2004 to 2017 describing studies focused on youth with ID with no significant co-occurring physical diagnoses who were transitioning from U.S.-based school settings to paid employment. Data extraction was managed using Google Drive. Data were organized on extraction sheets by trained reviewers. The quality of each study was assessed using questions adapted from the Critical Appraisal Skills Program checklist.

FINDINGS

A total of 35 articles were included, 7 of which used randomized controlled designs. All articles described interventions aligned with the Occupational Therapy Practice Framework: Domain and Process (3rd ed.), but specific mention of occupational therapy was notably absent from the literature. Interventions had little and generally low-level evidence supporting their use.

CONCLUSIONS AND RELEVANCE

Significant and concerning gaps exist in the literature on school-to-work transition for youth with ID, likely impeding evidence-based practice. No included article mentioned occupational therapy or had a contributor who was an occupational therapy practitioner. Practitioners should advocate for occupational therapy's role in transition and contribute reports of occupational therapy transition services for youth with ID to the literature.

WHAT THIS ARTICLE ADDS

This study demonstrates that occupational therapy is poorly represented in literature describing transition services for youth with ID. Although the articles described interventions within the occupational therapy domain, these interventions were not provided by occupational therapy practitioners and did not have a strong evidence base.

Interviewer- versus self-administration of PROMIS® measures for adults with traumatic injury

OBJECTIVE

To assess differential item functioning and observed mean differences across two modes of administration for PROMIS® measure scores in a sample of adults with traumatic injury.

METHOD

Items from 7 PROMIS® adult measures (v1.0 Physical Function, Fatigue, Pain Interference, Anger, Anxiety, and Depression and v2.0 Social Health-Emotional Support) were administered as fixed-length short forms in random order to a cross-sectional sample. Participants were randomly assigned to interviewer-administered (phone or in-person) or self-administered (via the Assessment Center website) conditions. The research was conducted at 5 medical rehabilitation institutions across the U.S. Participants included 277 adults with spinal cord injury (n = 148) or traumatic brain injury (n = 129).

RESULTS

DIF analyses indicated that all items were invariant to mode of administration. There was no significant effect of mode of administration for the majority of PROMIS® measures tested. Regarding observed scores, there were small but significant effects of mode of administration on the Emotional Support and Depression measures, with participants in the interview condition reporting better support/fewer symptoms.

CONCLUSIONS

PROMIS® instruments demonstrated measurement equivalence across interviewer-administered and self-administered conditions. These findings are particularly important for research or clinical applications where administration of PROMIS® measures by independent web- or tablet-based administration is not ideal, for example with individuals with physical or cognitive disabilities or with individuals who lack computer and/or Internet access. PROMIS® v1.0 Depression and PROMIS® v2.0 Emotional Support scores displayed a tendency toward social desirability that should be considered when these measures are interviewer-administered. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Progressive Neuromuscular Scoliosis Secondary to Spinal Cord Injury in a Young Patient Treated With Nonfusion Anterior Scoliosis Correction

Ninety-eight percent of skeletally immature patients with spinal cord injury (SCI) suffer from progressive neuromuscular scoliosis (NMS). Operative treatment has typically been limited to posterior spinal fusion (PSF), but a newer technique as described may be less invasive and preserve more function. A PSF of the entire spine to the pelvis is standard of care. However, maintenance of spinal flexibility, motion, and potential growth is desirable. We present a case for proof-of-concept of utilizing a surgical motion-preserving technique to treat progressive NMS in an 11year-old girl with T10 level (AIS B) paraplegia with a progressive 60° NMS of the lumbar spine. She had anterior scoliosis correction (ASC) from T11-L5 without fusion. Over 24 months, the curve growth-modulated to a residual of 12° with continued modulation to 7° at 3-year follow-up (skeletal maturity).

Interrater Reliability of the Pediatric Neuromuscular Recovery Scale for Spinal Cord Injury

Background: In synergy with the mounting scientific evidence for the capacity of recovery after spinal cord injury (SCI) and training, new evidence-based therapies advancing neuromuscular recovery are emerging. There is a parallel need for outcome instruments that specifically address recovery. The Pediatric Neuromuscular Recovery Scale (Pediatric NRS) is one example with established content validity to assess neuromuscular capacity within task performance. Objective: The objective of this study was to determine interrater reliability of the Pediatric NRS to classify motor capacity in children after SCI. Methods: Pediatric physicians (3), occupational therapists (5), and physical therapists (6) received standardized training in scoring the scale, then rated video assessments of 32 children post SCI, 2-12 years of age, 78% non-ambulatory. Interrater reliability was analyzed using Kendall coefficient of concordance for individual Pediatric NRS items and overall score. Results: The interrater reliability coefficient was determined to be near 1 for the overall Pediatric NRS score (ICC = 0.966; 95% CI, 0.89-0.98). Twelve of 16 individual items exhibited high concordance coefficients (Kendall's W ≥ 0.8) and four items demonstrated concordance coefficients, < 0.8 and > 0.69. Interrater reliability was equivalent among groups defined by age and neurological level, but lower among non-ambulatory individuals. Conclusion: Strong interrater reliability was demonstrated by pediatric clinicians who scored children with SCI using the Pediatric NRS.

Functional Gains in Children With Spastic Hemiplegia Following a Tendon Achilles Lengthening Using Computerized Adaptive Testing-A Pilot Study

Purpose:

This pilot study evaluated the outcomes of tendon Achilles lengthening in 12 children (mean age: 11.2 years) with spastic hemiplegia.

Methods:

Cerebral Palsy Computer Adaptive Tests, the timed up-and-go, the Gross Motor Function Measure, the Gillette Functional Assessment Questionnaire, and the Pediatric Outcomes Data Collection Instrument were administered at baseline and at 6, 12, and 24 months postsurgery.

Results:

Significant improvement at the latest follow-up (12-24 months following surgery) was seen in all domains of the Cerebral Palsy Computer Adaptive Test: activity (P = .017), lower extremity (P = .005), global (P = .005), pain (P = .005), and fatigue (P = .028), as well as in the Gross Motor Function Measure-standing domain (P = .02) and the mobility domain of the Pediatric Outcomes Data Collection Instrument (P = .04).

Conclusion:

These findings indicate that the tendon Achilles lengthening improved functional outcome in these children as measured by tests of physical function, walking speed, and activity performance.

Activity-based Rehabilitation Interventions of the Neurologically Impaired Upper Extremity: Description of a Scoping Review Protocol

Introduction: A scoping review provides a means to synthesize and present a large body of literature on a broad topic, such as methods for various upper extremity activity-based therapy (ABT) interventions. Objectives: To describe our scoping review protocol to evaluate peer-reviewed articles focused on ABT interventions for individuals with neurologically impaired upper extremities. Methods: At Jefferson College of Health Professions and Sidney Kimmel Medical College at Jefferson, Philadelphia, the authors will follow this protocol to conduct a scoping review by establishing a research question and conducting a search of bibliographic databases to identify relevant studies. Using specific inclusion and exclusion criteria, abstracts will be screened and full-text articles will be reviewed for inclusion in charting, summarizing, and reporting results of appropriate studies. Conclusion: This protocol will guide the scoping review process to develop a framework for establishing a noninvasive ABT intervention informed by evidence for individuals with neurologically impaired upper extremities.

Evaluation of the Capabilities of Upper Extremity Test (CUE-T) in Children With Tetraplegia

Background: The Capabilities of Upper Extremity Test (CUE-T) is a spinal cord injury (SCI)-specific instrument based on the CUE Questionnaire (CUE-Q). Objective: To evaluate the psychometric properties of CUE-T in children with cervical SCI and determine the lowest age appropriate for test administration. Method: In this repeated measures multicenter study, 39 youths, mean age 12.3 years and mean time post injury 5.14 years, completed two administrations of the CUE-T. Test-retest reliability, internal consistency, and known groups validity were measured. Concurrent and discriminant validity were measured against previously validated measures: CUE-Q, Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP), Spinal Cord Independence Measure (SCIM) III, SCIM III-Self Care (SCIM-SC), and SCIM-Mobility. Results: The CUE-T scores demonstrated strong test-retest reliability (ICC ≥ 0.95), strong internal consistency (α ≥ 0.90), and acceptable individual item agreement (κ ≥ 0.49). The hand subscale had better scores (p < .05) for the motor incomplete versus complete known groups, and the arm, hand, and side subscales had better scores (p < .05) for higher versus lower strength groups. The CUE-T had strong concurrent validity with the CUE-Q (r = 0.85-0.87), GRASSP (r = 0.78-0.90), and SCIM-SC (r = 0.70) and moderate-to-weak correlation with the total SCIM (r = 0.65) and SCIM-Mobility (r = 0.51). Children older than 6 years with mature grasp patterns were able to complete the CUE-T. Conclusion: The CUE-T scores are reliable and valid for use in children with cervical SCI older than 6 years of age.

Diffusion Tensor Imaging Assessment of Regional White Matter Changes in the Cervical and Thoracic Spinal Cord in Pediatric Subjects

There are no studies to date,describing changes in the diffusion tensor imaging (DTI) metrics of the white matter (WM) regions of the entire cervical and thoracic spinal cord (SC) remote from the lesion in pediatric spinal cord injury (SCI) subjects. The purpose of this study was to determine whether DTI at sites cephalad and caudal to a lesion provides measures of cord abnormalities in children with chronic SCI. A retrospective study included 10 typically developing subjects (TD) and 10 subjects with chronic SCI who underwent SC imaging in 2014-2017. Axial diffusion tensor images using an inner field of view DTI sequence were acquired to cover the entire cervical and thoracic SC. Regions of interest were drawn on the SC WM: right and left lateral (motor), ventral (motor), and dorsal (sensory) tracts. To detect differences in DTI metrics between TD and SCI of the cord, a one way analysis of variance with pooled t test was performed. A stepwise regression analysis was performed to assess the correlation between DTI metrics and clinical scores. In motor and sensory tracts, fractional anisotropy (FA) and axial diffusivity (AD) were significantly decreased in the proximal segments of the caudal cord. In motor tracts cephalad to the lesion, FA was significantly decreased whereas AD was significantly increased in the proximal segment; however, AD was decreased in the distal and middle segments. International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) total score was significantly correlated with FA and AD of the motor and sensory tracts cephalad to the lesion. This study demonstrates that FA and AD have the potential to be sensitive biomarkers of the full extent of cord injury and might be useful in detecting remote injuries to the SC and in guiding new treatments.

Examination of psychometric properties of PROMIS®: Pediatric upper limb measures in youth with cerebral palsy

Introduction

This study examines the validity and distribution characteristics of the PROMIS® pediatric upper limb measures in a sample of young people with cerebral palsy.

Method

Data are a cross-sectional subset of a larger prospective study of the responsiveness to change of PROMIS® pediatric measures following surgery to improve functioning in young people with cerebral palsy. Ninety-three participants between the ages of eight and 21 years completed the PROMIS® pediatric mobility and upper limb computer adaptive tests and short forms in conjunction with a set of static “legacy” measures of physical functioning, including a parent-report of upper limb function.

Results

The PROMIS® Pediatric upper limb short form demonstrated acceptable internal consistency (Cronbach’s alpha = 0.85). PROMIS® pediatric upper limb computer adaptive tests and short form mean values (42.1(11) and 43(10.4), respectively) were nearly 1 SD below normal, which is appropriate when a generic measure is used in a sample of young persons with cerebral palsy. The PROMIS® pediatric upper limb computer adaptive tests had a higher frequency of ceiling effects (29.50%) compared to the short form (18.30%).

Conclusion

Results of this study suggest that the PROMIS® pediatric upper limb computer adaptive tests and the short form are valid indicators of upper limb function in young people with cerebral palsy. The item bank can be replenished to address ceiling effects.

Age related diffusion and tractography changes in typically developing pediatric cervical and thoracic spinal cord

Background and objective

Diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) are two techniques that can measure white matter integrity of the spinal cord. Recently, DTI indices have been shown to change with age. The purpose of this study is (a) to evaluate the maturational states of the entire pediatric spinal cord using DTI and DTT indices including fractional anisotropy (FA), mean diffusivity (MD), mean length of white matter fiber tracts and tract density and (b) to analyze the DTI and DTT parameters along the entire spinal cord as a function of spinal cord levels and age.

Method

A total of 23 typically developing (TD) pediatric subjects ranging in age from 6 to 16 years old (11.94 ± 3.26 (mean ± standard deviation), 13 females and 10 males) were recruited, and scanned using 3.0 T MR scanner. Reduced FOV diffusion tensor images were acquired axially in the same anatomical location prescribed for the T2-weighted images to cover the entire spinal cord (C1-mid L1 levels). To mitigate motion induced artifacts, diffusion directional images were aligned with the reference image (b0) using a rigid body registration algorithm performed by in-house software developed in Matlab (MathWorks, Natick, Massachusetts). Diffusion tensor maps (FA and MD) and streamline deterministic tractography were then generated from the motion corrected DTI dataset. DTI and DTT parameters were calculated by using ROIs drawn to encapsulate the whole cord along the entire spinal cord by an independent board certified neuroradiologist. These indices then were compared between two age groups (age group A = 6-11 years (n = 11) and age group B = 12-16 years (n = 12)) based on similar standards and age definitions used for reporting spinal cord injury in the pediatric population. Standard least squared linear regression based on a restricted maximum likelihood (REML) method was used to evaluate the relationship between age and DTI and DTT parameters.

Results

An increase in FA (group A = 0.42 ± 0.097, group B = 0.49 ± 0.116), white matter tract density (group A = 368.01 ± 236.88, group B = 440.13 ± 245.24) and mean length of fiber tracts (group A = 48.16 ± 20.48 mm, group B = 60.28 ± 23.87 mm) and a decrease in MD (group A = 1.06 ± 0.23 × 10-3 mm2/s, group B = 0.82 ± 0.24 × 10-3 mm2/s) were observed with age along the entire spinal cord. Statistically significant increases have been shown in FA (p = 0.004, R2 = 0.57), tract density (p = 0.0004, R2 = 0.58), mean length of fiber tracts (p < 0.001, R2 = 0.5) and a significant decrease has been shown in MD (p = 0.002, R2 = 0.59) between group A and group B. Also, it has been shown DTI and DTT parameters vary along the spinal cord as a function of intervertebral disk and mid-vertebral body level.

Conclusion

This study provides an initial understanding of age related changes of DTI values as well as DTT metrics of the spinal cord. The results show significant differences in DTI and DTT parameters which may result from decreasing water content, myelination of fiber tracts, and the thickening diameter of fiber tracts during the maturation process. Consequently, when quantitative DTI and DTT of the spinal cord is undertaken in the pediatric population an age and level matched normative dataset should be used to accurately interpret the quantitative results.

Considerations and recommendations for selection and utilization of upper extremity clinical outcome assessments in human spinal cord injury trials

Study design

This is a focused review article.

Objectives

This review presents important features of clinical outcomes assessments (COAs) in human spinal cord injury research. Considerations for COAs by trial phase and International Classification of Functioning, Disability and Health are presented as well as strengths and recommendations for upper extremity COAs for research. Clinical trial tools and designs to address recruitment challenges are identified.

Methods

The methods include a summary of topics discussed during a two-day workshop, conceptual discussion of upper extremity COAs and additional focused literature review.

Results

COAs must be appropriate to trial phase and particularly in mid-late-phase trials, should reflect recovery vs. compensation, as well as being clinically meaningful. The impact and extent of upper vs. lower motoneuron disease should be considered, as this may affect how an individual may respond to a given therapeutic. For trials with broad inclusion criteria, the content of COAs should cover all severities and levels of SCI. Specific measures to assess upper extremity function as well as more comprehensive COAs are under development. In addition to appropriate use of COAs, methods to increase recruitment, such as adaptive trial designs and prognostic modeling to prospectively stratify heterogeneous populations into appropriate cohorts should be considered.

Conclusions

With an increasing number of clinical trials focusing on improving upper extremity function, it is essential to consider a range of factors when choosing a COA.

Sponsors

Craig H. Neilsen Foundation, Spinal Cord Outcomes Partnership Endeavor.

Despite limitations in content range, the SCIM-III is reproducible and a valid indicator of physical function in youths with spinal cord injury and dysfunction

STUDY DESIGN

Multi-center, repeated measures OBJECTIVES: Evaluate psychometric properties of the SCIM-III in children.

SETTING

Seven facilities in North America METHODS: One-hundred and twenty-seven youths, mean age of 10.8 years and chronic spinal cord injury/dysfunction completed two administrations of the Spinal Cord Independence Measure-III (SCIM-III). Mean, standard deviation, range values were calculated for SCIM-III total and subscales for the entire sample, four age groups and injury characteristics. Test-retest reliability, concurrent validity, and floor and ceiling effects were examined.

RESULTS

Total SCIM-III and self-care (SC) subscale scores for the youngest age group were lower than those for the three older age groups. There were statistically significant differences in SC subscale scores between neurological level (NL) C5-T1 and T2 -T12; C5-T1 and L1-S4/5; and T2-T12 and L1-S4/5 and in in-room, and indoor/outdoor mobility subscale scores between C1-C4 and T2-T12; C1-C4 and L1-S4/5; C5-T1 and T2-T12; C5-T1 and L1-S4/5; and T2-T12 and L1-S4/5. All scores between motor complete and motor incomplete differed. Test-retest reliability was good (ICC values = > 0.84) and there was moderate to strong correlation between SCIM-III and the FIM® Instrument (r = 0.77-0.92). Ceiling effects were present in the SC subscale for the oldest age group (24%) and for NL L1-S4/5 (35.5%) and in in-room mobility subscale for 6-12 (45.7%), 13-15 (30.43%) and 16-17 (60%) ages, paraplegia (42.4%), tetraplegia (37.1%), incomplete injuries (50%), and T2-T12 (38%) and L1-S4/5 (100%) NL.

CONCLUSION

Despite limitations in content range, the SCIM-III is reproducible, and a valid indicator of physical functioning in youth with SCI/D 6 years of age and older.

SPONSORSHIP

The study was funded by the Craig H. Neilsen Foundation, Spinal Cord Injury Research on the Translation Spectrum, Senior Research Award Grant #282592 (Mulcahey, PI).

Identification of ghost artifact using texture analysis in pediatric spinal cord diffusion tensor images

PURPOSE

Ghost artifacts are a major contributor to degradation of spinal cord diffusion tensor images. A multi-stage post-processing pipeline was designed, implemented and validated to automatically remove ghost artifacts arising from reduced field of view diffusion tensor imaging (DTI) of the pediatric spinal cord.

METHOD

A total of 12 pediatric subjects including 7 healthy subjects (mean age=11.34years) with no evidence of spinal cord injury or pathology and 5 patients (mean age=10.96years) with cervical spinal cord injury were studied. Ghost/true cords, labeled as region of interests (ROIs), in non-diffusion weighted b0 images were segmented automatically using mathematical morphological processing. Initially, 21 texture features were extracted from each segmented ROI including 5 first-order features based on the histogram of the image (mean, variance, skewness, kurtosis and entropy) and 16s-order feature vector elements, incorporating four statistical measures (contrast, correlation, homogeneity and energy) calculated from co-occurrence matrices in directions of 0°, 45°, 90° and 135°. Next, ten features with a high value of mutual information (MI) relative to the pre-defined target class and within the features were selected as final features which were input to a trained classifier (adaptive neuro-fuzzy interface system) to separate the true cord from the ghost cord.

RESULTS

The implemented pipeline was successfully able to separate the ghost artifacts from true cord structures. The results obtained from the classifier showed a sensitivity of 91%, specificity of 79%, and accuracy of 84% in separating the true cord from ghost artifacts.

CONCLUSION

The results show that the proposed method is promising for the automatic detection of ghost cords present in DTI images of the spinal cord. This step is crucial towards development of accurate, automatic DTI spinal cord post processing pipelines.

International spinal cord injury bowel function basic data set (Version 2.0)

STUDY DESIGN

International expert working group.

OBJECTIVES

To revise the International Spinal Cord Injury (SCI) Bowel Function Basic Data Set as a standardized format for the collecting and reporting of a minimal amount of information on bowel function in clinical practice and research.

SETTING

Working group appointed by the American Spinal injury association (ASIA) and the International Spinal Cord Society (ISCoS).

METHODS

The draft prepared by the working group was reviewed by the International SCI Data Set Committee and later by members of the ISCoS Executive and Scientific Committees and the ASIA board. The revised data set was posted on the ASIA and ISCoS websites for 1 month to allow further comments and suggestions. Changes resulting from a Delphi process among experts in children with SCI were included. Members of ISCoS Executive and Scientific Committees and the ASIA board made a final review and approved the data set.

RESULTS

The International SCI Bowel Function Basic Data Set (Version 2.0) consists of the following 16 items: date of data collection, gastrointestinal and anal sphincter dysfunction unrelated to SCI, surgical procedures on the gastrointestinal tract, defecation method and bowel-care procedures, average time required for defecation, frequency of defecation, uneasiness, headache or perspiration during defecation, digital stimulation or evacuation of the anorectum, frequency of fecal incontinence, flatus incontinence, need to wear pad or plug, oral laxatives and prokinetics, anti-diarrheal agents, perianal problems, abdominal pain and discomfort and the neurogenic bowel dysfunction score.

CONCLUSION

The International SCI Bowel Function Basic Data Set (Version 2.0) has been developed.

Differential item functioning in the Patient Reported Outcomes Measurement Information System Pediatric Short Forms in a sample of children and adolescents with cerebral palsy

AIM

The present study examined the Patient Reported Outcomes Measurement Information System (PROMIS) Mobility, Fatigue, and Pain Interference Short Forms (SFs) in children and adolescents with cerebral palsy (CP) for the presence of differential item functioning (DIF) relative to the original calibration sample.

METHOD

Using the Graded Response Model we compared item parameter estimates generated from a sample of 303 children and adolescents with CP (175 males, 128 females; mean age 15y 5mo) to parameter estimates from the PROMIS calibration sample, which served as the reference group. DIF was assessed in a two-step process using the item response theory-likelihood ratio-differential item functioning detection procedure.

RESULTS

Significant DIF was identified for four of eight items in the PROMIS Mobility SF, for two of eight items in the Pain Interference Scale, and for one item out of 10 on the Fatigue Scale. Impact of DIF on total score estimation was notable for Mobility and Pain Interference, but not for Fatigue.

INTERPRETATION

Results suggest differences in the responses of adolescents with CP to some items on the PROMIS Mobility and Pain Interference SFs. Cognitive interviews about the PROMIS items with adolescents with varying degrees of mobility limitations would provide better understanding of how they are interpreting and selecting responses to the PROMIS items and thus help guide selection of the most appropriate way to address this issue.

Ability of PROMIS Pediatric Measures to Detect Change in Children With Cerebral Palsy Undergoing Musculoskeletal Surgery

BACKGROUND

The Patient Reported Outcomes Measurement Information System (PROMIS) was developed to provide patient-reported outcome measures that are designed as being universally relevant across health conditions, low burden, and precise. A major problem for research and clinical practice in cerebral palsy (CP) is the void of outcomes instruments that are capable of evaluating the wide range of abilities and broad age spectrum inherent in this clinical population. Given the tremendous potential of PROMIS, the research questions for this study were "How do PROMIS pediatric computer adaptive tests and short forms detect change in children with CP following elective musculoskeletal surgery?" and "How do PROMIS instruments compare to the Pediatric Quality of Life Inventory Cerebral Palsy Module Version 3.0 (PedsQL CP), Pediatric Outcomes Data Collection Instrument (PODCI), the Timed Up and Go (TUG), and the Gross Motor Functional Measure (GMFM)."

METHODS

PROMIS Pediatric computer adaptive tests and short forms and the PedsQL, PODCI, TUG, and GMFM were administered before and after surgery. Effect size (ES) and standardized response mean (SRM) were calculated. Floor and ceiling effects were evaluated and, exposure rates for the PROMIS item banks were examined.

RESULTS

ES and SRM for all PROMIS Pediatric Measures were nonsignificant. PedsQL CP detected significant, positive change in mobility at 6 (ES=0.26; SRM=0.31) and 12 (ES=0.36; SRM=0.36) months; pain at 12 months (ES=0.29; SRM=0.34); and fatigue at 6 (ES=0.24; SRM=0.22) and 12 (ES=0.36; SRM=0.41) months. Significant negative changes were detected by the PODCI (ES=-0.20; SRM=-0.26), GMFM (ES=-0.13; SRM=-0.24), and TUG (ES=-0.29; SRM=-0.25). Ceiling effects were high. Exposure to an appropriate range of the PROMIS Mobility item bank was limited.

CONCLUSIONS

PROMIS measures were less able to detect change than other measures. PROMIS measures may be improved by tailoring start/stop rules or by adding items to include content appropriate for children with mobility impairments.

LEVEL OF EVIDENCE

Level III-diagnostic study.

Diffusion Tensor Imaging of the Normal Cervical and Thoracic Pediatric Spinal Cord

BACKGROUND AND PURPOSE

DTI data of the normal healthy spinal cord in children are limited compared with adults and are typically focused on the cervical spinal cord. The purpose of this study was the following: to investigate the feasibility of obtaining repeatable DTI parameters along the entire cervical and thoracic spinal cord as a function of age in typically developing pediatric subjects; to analyze the DTI parameters among different transverse levels of the cervical and thoracic spinal cord; and to examine the sex differences in DTI parameters along the cervical and thoracic spinal cord.

MATERIALS AND METHODS

Twenty-two subjects underwent 2 identical scans by using a 3T MR imaging scanner. Axial diffusion tensor images were acquired by using 2 overlapping slabs to cover the cervical and thoracic spinal cord. After postprocessing, DTI parameters were calculated by using ROIs drawn on the whole cord along the entire spinal cord for both scans.

RESULTS

An increase in fractional anisotropy and a decrease in mean diffusivity, axial diffusivity, and radial diffusivity were observed with age along the entire spinal cord. Significantly lower fractional anisotropy and higher mean diffusivity values were observed in the lower cervical cord compared with the upper cervical cord. Axial diffusivity values in the cervical cord were higher compared with the thoracic cord. No statistically significant sex differences were observed for all DTI parameters. There was a moderate-to-strong repeatability for all DTI parameters.

CONCLUSIONS

This study provides an initial understanding of DTI values of the spinal cord relevant to age and sex and shows that obtaining repeatable DTI values of the entire cord in children is feasible.

Measuring activity limitation outcomes in youth with spinal cord injury

STUDY DESIGN

A cross-sectional study.

OBJECTIVES

The Pediatric Spinal Cord Injury Activity Measure (PEDI-SCI AM), which includes calibrated item banks (child and parent versions) for general mobility, daily routines, wheeled mobility and ambulation, can be administered using computerized adaptive tests (CATs) or short forms (SFs). The study objectives are as follows: (1) to examine the psychometric properties of the PEDI-SCI AM item banks and 10-item CATs; and (2) to develop and evaluate the psychometric properties of PEDI-SCI AM SFs.

SETTING

US Shriners Hospitals for Children (California, Illinois and Pennsylvania).

METHODS

Calibration data from a convenience sample of 381 children and adolescents with SCI and 322 parents or caregivers were used to examine PEDI-SCI AM item banks, 10-item CATs and SF scores. We calculated group reliability, internal consistency (Cronbach's alpha) and interclass coefficients (ICCs) to assess agreement between 10-item CATs, SFs and item banks. The percent of the sample with highest (ceiling) and lowest (floor) scores was also determined. An expert panel selected items for 14 SFs.

RESULTS

PEDI-SCI item banks, 10-item CATs and SFs demonstrate acceptable group reliability (0.73-0.96) and internal consistency (0.77-0.98). ICC values show strong agreement with item banks for 10-item CATs (0.72-0.99) and SFs. Floor effects are minimal (<15%). Ceiling effects are minimal for children with tetraplegia but high in children with paraplegia for general mobility (13.41-26.05%) and daily activities (12.99-32.71%).

CONCLUSIONS

The PEDI-SCI AM exhibited strong psychometric properties for children with tetraplegia. Replenishment of the general mobility and daily routine item banks is needed to reduce ceiling effects noted for youth with paraplegia.

Spatially selective 2D RF inner field of view (iFOV) diffusion kurtosis imaging (DKI) of the pediatric spinal cord

Magnetic resonance based diffusion imaging has been gaining more utility and clinical relevance over the past decade. Using conventional echo planar techniques, it is possible to acquire and characterize water diffusion within the central nervous system (CNS); namely in the form of Diffusion Weighted Imaging (DWI) and Diffusion Tensor Imaging (DTI). While each modality provides valuable clinical information in terms of the presence of diffusion and its directionality, both techniques are limited to assuming an ideal Gaussian distribution for water displacement with no intermolecular interactions. This assumption neglects pathological processes that are not Gaussian therefore reducing the amount of potentially clinically relevant information. Additions to the Gaussian distribution measured by the excess kurtosis, or peakedness, of the probabilistic model provide a better understanding of the underlying cellular structure. The objective of this work is to provide mathematical and experimental evidence that Diffusion Kurtosis Imaging (DKI) can offer additional information about the micromolecular environment of the pediatric spinal cord. This is accomplished by a more thorough characterization of the nature of random water displacement within the cord. A novel DKI imaging sequence based on a tilted 2D spatially selective radio frequency pulse providing reduced field of view (FOV) imaging was developed, implemented, and optimized on a 3 Tesla MRI scanner, and tested on pediatric subjects (healthy subjects: 15; patients with spinal cord injury (SCI):5). Software was developed and validated for post processing of the DKI images and estimation of the tensor parameters. The results show statistically significant differences in mean kurtosis (p < 0.01) and radial kurtosis (p < 0.01) between healthy subjects and subjects with SCI. DKI provides incremental and novel information over conventional diffusion acquisitions when coupled with higher order estimation algorithms.

•

Diffusion Kurtosis Imaging (DKI) was performed on pediatric subjects using a tilted 2D RF reduced field of view sequence.

•

Results show statistically significant differences in FA, MK, Krad, and Drad between healthy subjects and patients with SCI.

•

DKI provides additional structural information that when paired with DTI metrics could be used as a novel imaging biomarker.

Development and Initial Validation of the Pediatric Neuromuscular Recovery Scale

PURPOSE

The Neuromuscular Recovery Scale (NRS) was developed to assess the capacity of adults' post-spinal cord injury (SCI) to perform functional tasks without compensation. Application of the NRS to children has been challenging. The purpose of this study was to develop and complete the initial validation of a pediatric version of the NRS.

METHODS

First, the investigative team developed a draft Pediatric NRS. Next, a Delphi method was used to amend the draft by 12 pediatric experts. Finally, the revised Pediatric NRS was field-tested on a sample of children with SCI (n = 5) and without (n = 7).

RESULTS

After the Delphi process and field testing, the Pediatric NRS consists of 13 items scored on a 12-point scale. All items, except 1, achieved 80% agreement by experts.

CONCLUSIONS

This is the first step in development and validation of a pediatric SCI scale that evaluates neuromuscular capacity, in the context of pediatric function, without compensation.

Inter- and intra-rater reliability of diffusion tensor imaging parameters in the normal pediatric spinal cord

AIM

To assess inter- and intra-rater reliability (agreement) between two region of interest (ROI) methods in pediatric spinal cord diffusion tensor imaging (DTI).

METHODS

Inner-Field-of-View DTI data previously acquired from ten pediatric healthy subjects (mean age = 12.10 years) was used to assess for reliability. ROIs were drawn by two neuroradiologists on each subject data twice within a 3-mo interval. ROIs were placed on axial B0 maps along the cervical spine using free-hand and fixed-size ROIs. Agreement analyses for fractional anisotropy (FA), axial diffusivity, radial diffusivity and mean diffusivity were performed using intra-class-correlation (ICC) and Cronbach's alpha statistical methods.

RESULTS

Inter- and intra-rater agreement between the two ROI methods showed moderate (ICC = 0.5) to strong (ICC = 0.84). There were significant differences between raters in the number of pixels selected using free-hand ROIs (P < 0.05). However, no significant differences were observed in DTI parameter values. FA showed highest variability in ICC values (0.10-0.87). Cronbach's alpha showed moderate-high values for raters and ROI methods.

CONCLUSION

The study showed that high reproducibility in spinal cord DTI can be achieved, and demonstrated the importance of setting detailed methodology for post-processing DTI data, specifically the placement of ROIs.