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Mulcahey MJ, Calhoun CL, Sinko R, Kelly EH, Vogel LC. The spinal cord independence measure (SCIM)-III self report for youth. Spinal Cord 2015; 54:204-12. [PMID: 26078233 DOI: 10.1038/sc.2015.103] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/10/2015] [Accepted: 05/12/2015] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN The items and response scales of the Spinal Cord Independence Measure (SCIM-III) self report (SR) were exposed to formal cognitive testing with children with SCI, and in parallel a survey using the modified Delphi Technique was conducted to engage content experts in an iterative critical review of the SCIM-III SR. OBJECTIVES To evaluate the validity of the SCIM-III SR for pediatric utilization. SETTING United States of America. METHODS Formal cognitive testing was conducted with 17 youths with SCI and required them to read and answer each SCIM-III SR item aloud. Think aloud methodology was used to record details about how youths understood and interpreted items and why they selected a given response. The interviews were audiotaped and transcribed verbatim. Content analysis focused on identifying words that children could not read or understand. In parallel, the Modified Delphi Technique engaged expert therapists to critically review the SCIM-III SR for pediatric utilization. RESULTS Every SCIM-III SR item and response scale required modification before children were able to read, understand and respond to them. Youth encountered difficulties because of vague terms, medical jargon and complex words and phrases. Three iterative Delphi rounds were required before achieving 80% agreement that items and response scales were written well for children. CONCLUSION Our findings informed modifications to every SCIM-III SR item and response scale, producing a pediatric version of the tool that we formally refer to as the SCIM-III SR-Youth (SCIM-III SR-Y). SPONSORSHIP The study was funded by the Craig H Neilsen Foundation, Spinal Cord Injury Research on the Translation Spectrum, Senior Research Award #282592 (Mulcahey, PI).
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Kirshblum SC, Biering-Sørensen F, Betz R, Burns S, Donovan W, Graves DE, Johansen M, Jones L, Mulcahey MJ, Rodriguez GM, Schmidt-Read M, Steeves JD, Tansey K, Waring W. International standards for neurological classification of spinal cord injury: cases with classification challenges. Top Spinal Cord Inj Rehabil 2014; 20:81-9. [PMID: 25477729 DOI: 10.1310/sci2002-81] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) is routinely used to determine levels of injury and to classify the severity of the injury. Questions are often posed to the International Standards Committee of the American Spinal Injury Association (ASIA) regarding the classification. The committee felt that disseminating some of the challenging questions posed, as well as the responses, would be of benefit for professionals utilizing the ISNCSCI. Case scenarios that were submitted to the committee are presented with the responses as well as the thought processes considered by the committee members. The importance of this documentation is to clarify some points as well as update the SCI community regarding possible revisions that will be needed in the future based upon some rules that require clarification.
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Muller M, Toth-Cohen S, Mulcahey MJ. Development and evaluation of a hospital-based peer support group for younger individuals with stroke. Occup Ther Health Care 2014; 28:277-295. [PMID: 24971895 DOI: 10.3109/07380577.2014.919551] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The incidence of stroke in younger individuals is rising, producing unique challenges due to loss of productive roles and long-term impact in the survivor's life. This paper reports the results of a hospital-based program based on occupational therapy principles that was designed to provide support and education for 13 younger individuals (<65) with stroke. Participants demonstrated improved socialization, healthy coping, and role attainment as measured by the Stroke Impact Scale (SIS), the Community Integration Questionnaire (CIQ), and a member satisfaction questionnaire. Key factors for successful implementation and considerations for future programs to meet the needs of younger adults with stroke are discussed.
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Biering-Sørensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International Spinal Cord Injury Upper Extremity Basic Data Set. Spinal Cord 2014; 52:652-7. [DOI: 10.1038/sc.2014.87] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 04/28/2014] [Accepted: 05/03/2014] [Indexed: 11/09/2022]
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Kratz AL, Slavin MD, Mulcahey MJ, Jette AM, Tulsky DS, Haley SM. An examination of the PROMIS(®) pediatric instruments to assess mobility in children with cerebral palsy. Qual Life Res 2013; 22:2865-76. [PMID: 23543391 PMCID: PMC3758380 DOI: 10.1007/s11136-013-0397-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2013] [Indexed: 12/31/2022]
Abstract
PURPOSE The Patient-Reported Outcomes Measurement Information System (PROMIS(®)) provides adult and pediatric self-report measures of health-related quality of life designed for use across medical conditions and the general population. The purpose of this study was to examine the feasibility and validity of the PROMIS(®) Pediatric Short Form and computer-adaptive test (CAT) mobility measures in children with cerebral palsy (CP). METHODS Eighty-two children with CP completed self-report (PROMIS(®) Mobility Short Form, PROMIS(®) Mobility CAT, Pediatric Quality of Life Inventory™) and performance-based assessments of mobility (Timed Up and Go, Gross Motor Function Measure). Parents provided three proxy reports of child mobility (Pediatric Outcomes Data Collection Instrument, Functional Assessment Questionnaire, Shriners Hospitals for Children CP-CAT). Validity of PROMIS(®) instruments was examined through correlations with other measures and "known groups" analyses determined by Gross Motor Function Classification System (GMFCS). RESULTS On average, the PROMIS(®) CAT required less than seven items and 2 minutes to administer. Both PROMIS(®) measures showed moderate to high correlations with child- and parent-proxy report of child mobility; correlations with performance-based measure were small for the PROMIS(®) Short Form and non-significant for the PROMIS(®) CAT. All measures except for the PROMIS(®) CAT were able to distinguish between GMFCS categories. CONCLUSIONS Results support the convergent and discriminant validity of the pediatric PROMIS(®) Mobility Short Form in children with CP. The PROMIS(®) Mobility CAT correlates well with child report and parent report of mobility but not with performance-based measures and does not differentiate between known mobility groups.
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Burns S, Biering-Sørensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov A, Kirshblum S, Mulcahey MJ, Read MS, Waring W. International standards for neurological classification of spinal cord injury, revised 2011. Top Spinal Cord Inj Rehabil 2013; 18:85-99. [PMID: 23460761 DOI: 10.1310/sci1801-85] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Chafetz RS, Gaughan JP, Calhoun C, Schottler J, Vogel LC, Betz R, Mulcahey MJ. Relationship between neurological injury and patterns of upright mobility in children with spinal cord injury. Top Spinal Cord Inj Rehabil 2013; 19:31-41. [PMID: 23678283 DOI: 10.1310/sci1901-31] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The predictors and patterns of upright mobility in children with a spinal cord injury (SCI) are poorly understood. OBJECTIVE The objective of this study was to develop a classification system that measures children's ability to integrate ambulation into activities of daily living (ADLs) and to examine upright mobility patterns as a function of their score and classification on the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam. METHODS This is a cross-sectional, multicenter study that used a convenience sample of subjects who were participating in a larger study on the reliability of the ISNCSCI. A total of 183 patients between 5 and 21 years old were included in this study. Patients were asked if they had participated in upright mobility in the last month and, if so, in what environment and with what type of bracing. Patients were then categorized into 4 groups: primary ambulators (PrimA), unplanned ambulators (UnPA), planned ambulators (PlanA), and nonambulators. RESULTS Multivariate analyses found that only lower extremity strength predicted being a PrimA, whereas being an UnPA was predicted by both lower extremity strength and lack of preservation of S45 pinprick sensation. PlanA was only associated with upper extremity strength. CONCLUSIONS This study introduced a classification system based on the ability of children with SCI to integrate upright mobility into their ADLs. Similar to adults, lower extremity strength was a strong predictor of independent mobility (PrimA and UnPA). Lack of pinprick predicted unplanned ambulation, but not being a PrimA. Finally, upper extremity strength was a predictor for planned ambulation.
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Krisa L, Middleton D, Faro S, Calhoun CL, Mohamed FB, Mulcahey MJ. Cerebral activation during the test of spinal cord injury severity in children: an FMRI methodological study. Top Spinal Cord Inj Rehabil 2013; 19:121-8. [PMID: 23671382 DOI: 10.1310/sci1902-121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) are internationally accepted to determine and classify the extent of motor and sensory impairment along with severity (ASIA Impairment Scale [AIS]) following spinal cord injury (SCI). The anorectal examination is a component of the ISNCSCI that determines injury severity. There is a void in the health care literature on the validity of the anorectal examination as an indication of SCI severity. OBJECTIVE To validate the use of functional magnetic resonance imagining (fMRI) for the purpose of classifying the severity of SCI in children. METHODS Seventeen patients, with the average age of 14.3 years, underwent 1 complete ISNCSCI examination. Subjects also underwent the anorectal portion of this exam while fMRI data were collected using a 3.0 Tesla Siemens Verio Scanner. Cortical areas of activation were analyzed for possible differences of cortical involvement between complete (AIS A) and incomplete (AIS B, C, and D) SCI subjects. Anxiety/anticipation of the test was also assessed. RESULTS This study established an fMRI imaging protocol that captures the cortical locations and intensity of activation during the test of sacral sparing. In addition to developing the data acquisition protocol, we also established the postacquisition preprocessing and statistical analysis parameters using SPM8. CONCLUSION Preliminary findings indicate that fMRI is a useful tool in evaluating the validity of the anorectal examination in determining SCI severity. Assessment of which cortical regions are activated during the testing procedure provides an indication of which pathways are transmitting information to the brain.
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Hwang M, Zebracki K, Betz RR, Mulcahey MJ, Vogel LC. Normative blood pressure and heart rate in pediatric spinal cord injury. Top Spinal Cord Inj Rehabil 2013; 19:87-95. [PMID: 23671378 DOI: 10.1310/sci1902-87] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Mulcahey MJ, Gaughan JP, Betz RR, Samdani AF, Barakat N, Hunter LN. Neuromuscular scoliosis in children with spinal cord injury. Top Spinal Cord Inj Rehabil 2013; 19:96-103. [PMID: 23671379 DOI: 10.1310/sci1902-96] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The prevalence of neuromuscular scoliosis in children with spinal cord injury (SCI) is high. Published reports suggest that age at time of injury is the most important determinant. No studies have evaluated neurological characteristics using standardized methods to determine if they are strong predictors of scoliosis. OBJECTIVE To test the hypothesis that neurological level, motor score, and injury severity are strong predictors of neuromuscular scoliosis. METHODS Two hundred seventeen children were evaluated using the testing guidelines of the International Standards for Neurological Classification of Spinal Cord Injury. Cobb angles were calculated from plain radiographs as a measure of scoliosis. Multivariate analysis with statistical selection was used to determine predictors of worst Cobb angle and spinal fusion. The odds of having a spine fusion for subjects with at least 2-year follow-up and injured prior to (n=16) and after (n=91) 12 years of age were calculated. RESULTS The hypothesis was not supported. Although there was a very high prevalence (100%) of scoliosis in the study sample, age at time of injury was the only predictor of worst curve (P < .0001) and spine fusion (P < .007). The calculated odds ratio demonstrated that children injured <12 years were 3.7 times more likely to have a spine fusion (95% CI, 0.31-44.64). CONCLUSION There is a very high prevalence of neuromuscular scoliosis in pediatric SCI. Neurological level, motor level, and severity of injury are not strong predictors. Age is the only predictor of worst curve and spine fusion.
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Krisa L, Mulcahey MJ, Gaughan JP, Smith B, Vogel LC. Using a limited number of dermatomes as a predictor of the 56-dermatome test of the international standards for neurological classification of spinal cord injury in the pediatric population. Top Spinal Cord Inj Rehabil 2013; 19:114-20. [PMID: 23671381 DOI: 10.1310/sci1902-114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND For young children with spinal cord injury (SCI), the sensory exam of the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) is long and arduous, often making it impossible to complete. OBJECTIVES In this study, we determine whether an abbreviated sensory exam provides comparable information to the full 56-dermatome exam. METHOD A total of 726 56-dermatome sensory exams were completed with 190 children and youth with SCI ranging in age from 3 to 21 years. The cohort was randomly split into test and validation groups. For the test group, a principal component analysis (PCA) was carried out separately for pin prick (PP) and light touch (LT) scores. From the PCA, a hierarchical cluster analysis was performed to identify the most influential set of 4, 8, 12, and 16 dermatomes. From the sensory exam data obtained from the validation group, a linear regression was performed to compare the limited-dermatome composite scores to the total 56-dermatome scores. RESULTS For both LT and PP, the 16-dermatome test resulted in the best fit (0.86 and 0.87, respectively) with the 56-dermatome test and was comprised of dermatomes from both the left (7 dermatomes) and right (9 dermatomes) sides and at least 1 dermatome from each vertebral region bilaterally (cervical, thoracic, lumbar, sacral). CONCLUSION A 16-dermatome sensory exam provided a good correlation to the 56-dermatome exam. The shortened exam may be useful for evaluating children with SCI who cannot tolerate the full examination.
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Bent LM, Mulcahey MJ, Kelly EH, Calhoun CL, Tian F, Ni P, Vogel LC, Haley SM. Validity of computer adaptive tests of daily routines for youth with spinal cord injury. Top Spinal Cord Inj Rehabil 2013; 19:104-13. [PMID: 23671380 DOI: 10.1310/sci1902-104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the accuracy of computer adaptive tests (CATs) of daily routines for child- and parent-reported outcomes following pediatric spinal cord injury (SCI) and to evaluate the validity of the scales. METHODS One hundred ninety-six daily routine items were administered to 381 youths and 322 parents. Pearson correlations, intraclass correlation coefficients (ICC), and 95% confidence intervals (CI) were calculated to evaluate the accuracy of simulated 5-item, 10-item, and 15-item CATs against the full-item banks and to evaluate concurrent validity. Independent samples t tests and analysis of variance were used to evaluate the ability of the daily routine scales to discriminate between children with tetraplegia and paraplegia and among 5 motor groups. RESULTS ICC and 95% CI demonstrated that simulated 5-, 10-, and 15-item CATs accurately represented the full-item banks for both child- and parent-report scales. The daily routine scales demonstrated discriminative validity, except between 2 motor groups of children with paraplegia. Concurrent validity of the daily routine scales was demonstrated through significant relationships with the FIM scores. CONCLUSION Child- and parent-reported outcomes of daily routines can be obtained using CATs with the same relative precision of a full-item bank. Five-item, 10-item, and 15-item CATs have discriminative and concurrent validity.
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Mulcahey MJ, Samdani AF, Gaughan JP, Barakat N, Faro S, Shah P, Betz RR, Mohamed FB. Diagnostic accuracy of diffusion tensor imaging for pediatric cervical spinal cord injury. Spinal Cord 2013; 51:532-7. [PMID: 23608812 DOI: 10.1038/sc.2013.36] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 03/25/2013] [Accepted: 03/26/2013] [Indexed: 12/24/2022]
Abstract
STUDY DESIGN Cross-sectional non-experimental study. OBJECTIVES To examine diagnostic accuracy of diffusion tensor imaging (DTI) for pediatric spinal cord injury (SCI). SETTING Pediatric Orthopedic Hospital. METHODS Thirty-five subjects, 10 SCI and 25 controls, mean age 13.38 years underwent two scans with 3.0 T MR scanner. Fractional anisotropy (FA), axial diffusivity (AD) and radial diffusivity (RD) values were calculated. Subjects with SCI underwent examination of muscle strength, sensation and sacral sparing. Mean and s.d. values for FA, AD and RD were compared by group (controls, SCI with sacral sparing, SCI without sacral sparing) using analysis of variance for repeated measures. Comparisons were also made of DTI values at the injury site to values from cervical regions outside of the injury site. Specificity, sensitivity, receiver operating characteristics area under the curve (ROC AUC) and corresponding 95% confidence intervals were calculated. Resampling methods were used to validate the estimates from the final models. RESULTS FA values differed among SCI subjects with intact sacral sparing, absent sacral sparing and controls, P<0.003 (adjusted). DTI values in combination showed the strongest diagnostic accuracy for predicting the presence of anal contraction (AD, RD; ROC AUC=0.90), deep anal pressure (FA; ROC AUC=0.88), S4-5 sensation (FA, RD; ROC AUC=0.93), motor level (FA, AD, RD; ROC AUC=0.92) and MRI level (FA, AD, RD; ROC AUC=0.92). Bootstrap and Jackknife median values indicated consistency of the parameter estimates. CONCLUSION The predictive accuracy of DTI for sacral sparing end points and motor and MRI level of injury was good to strong.
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Lindwall JJ, Russell HF, Kelly EH, Klaas SJ, Mulcahey MJ, Betz RR, Vogel LC. Coping and participation in youth with spinal cord injury. Top Spinal Cord Inj Rehabil 2013; 18:220-31. [PMID: 23459106 DOI: 10.1310/sci1803-220] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Coping and participation are important adjustment outcomes of youth with spinal cord injury (SCI). Research addressing how these outcomes are related is limited. OBJECTIVE This cross-sectional study examined relationships between coping and participation in youth with SCI. METHOD Youth ages 7 to 18 years were recruited from 3 hospitals specializing in rehabilitation of youth with SCI. The Kidcope assessed coping strategies, and the Children's Assessment of Participation and Enjoyment (CAPE) examined participation patterns. Point biserial and Pearson correlations assessed relationships among variables, and hierarchical multiple regression analyses examined whether coping significantly contributed to participation above and beyond significant demographic and injury-related factors. RESULTS The sample included 294 participants: 45% female, 65% Caucasian, 67% with paraplegia. Mean age was 13.71 years (SD = 3.46), and mean duration of injury was 5.39 years (SD = 4.49). Results indicated that higher levels of social support and lower levels of self-criticism predicted higher participation in informal activities, lower levels of social withdrawal predicted participation in informal activities with a greater diversity of individuals, lower levels of blaming others predicted higher enjoyment of informal activities, and higher levels of cognitive restructuring predicted participation in formal activities with a greater diversity of individuals and in settings further from home. CONCLUSION Results suggest higher levels of social support and cognitive restructuring and lower levels of self-criticism, social withdrawal, and blaming others predicted favorable participation outcomes. Interventions for youth with SCI that encourage higher levels of positive coping strategies and lower levels of negative and avoidant strategies may promote positive participation outcomes.
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Krisa L, Gaughan J, Vogel L, Betz RR, Mulcahey MJ. Agreement of repeated motor and sensory scores at individual myotomes and dermatomes in young persons with spinal cord injury. Spinal Cord 2012; 51:75-81. [DOI: 10.1038/sc.2012.127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Barakat N, Mohamed FB, Hunter LN, Shah P, Faro SH, Samdani AF, Finsterbusch J, Betz R, Gaughan J, Mulcahey MJ. Diffusion tensor imaging of the normal pediatric spinal cord using an inner field of view echo-planar imaging sequence. AJNR Am J Neuroradiol 2012; 33:1127-33. [PMID: 22300927 PMCID: PMC8013244 DOI: 10.3174/ajnr.a2924] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 09/05/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE DTI in the brain has been well established, but its application in the spinal cord, especially in pediatrics, poses several challenges. The small cord size has inherent low SNR of the diffusion signal intensity, respiratory and cardiac movements induce artifacts, and EPI sequences used for obtaining diffusion indices cause eddy-current distortions. The purpose of this study was to 1) evaluate the accuracy of cervical spinal cord DTI in children using a newly developed iFOV sequence with spatially selective 2D-RF excitations, and 2) examine reproducibility of the DTI measures. MATERIALS AND METHODS Twenty-five typically developing subjects were imaged twice using a 3T scanner. Axial DTI images of the cervical spinal cord were acquired with this sequence. After motion correction, DTI indices were calculated using regions of interest manually drawn at every axial section location along the cervical spinal cord for both acquisitions. Various DTI indices were calculated: FA, AD, RD, MD, RA, and VR. Geometric diffusion measures were also calculated: Cp, Cl, and Cs. RESULTS The following average values for each index were obtained: FA = 0.50 ± 0.11; AD = 0.97 ± 0.20 × 10(-3)mm(2)/s; RD = 0.41 ± 0.13 × 10(-3)mm(2)/s; MD = 0.59 ± 0.15 × 10(-3)mm(2)/s; RA = 0.35 ± 0.08; VR = 0.03 ± 0.00; Cp = 0.13 ± 0.07; Cl = 0.29 ± 0.09; and Cs = 0.58 ± 0.11. The reproducibility tests showed moderate to strong ICC in all subjects for all DTI parameters (ICC>0.72). CONCLUSIONS This study showed that accurate and reproducible DTI parameters can be estimated in the pediatric cervical spinal cord using an iFOV EPI sequence.
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Barakat N, Mulcahey MJ, Shah P, Samdani A, Krisa L, Faro S, Mohamed FB. Diffusion tensor imaging in pediatric transverse myelitis: a case study. J Pediatr Rehabil Med 2012; 5:281-6. [PMID: 23411769 DOI: 10.3233/prm-2012-00222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Transverse myelitis is diagnosed based on the presence of spinal cord inflammation and the absence of infection to the central nervous system. In support of these criteria, patients undergo lumbar puncture to determine Cerebrospinal Fluid (CSF) pleocytosis and un-enhanced or Gadolinium-enhanced spinal Magnetic Resonance Imaging (MRI). We present the case of an 11~year-old previously healthy male who underwent a series of lab tests and MRI scans before a definite diagnosis of transverse myelitis four years prior to this study. The patient still shows deficits at the C4 cord level according to International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) examination, however, his MRI results are negative, and his Diffusion Tensor Imaging (DTI) results are close to values reported in healthy subjects.
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Vogel LC, Betz RR, Mulcahey MJ. Spinal cord injuries in children and adolescents. HANDBOOK OF CLINICAL NEUROLOGY 2012; 109:131-48. [PMID: 23098710 DOI: 10.1016/b978-0-444-52137-8.00008-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
This chapter provides an overview of spinal cord injuries (SCI) in children and adolescents, including epidemiology, medical and musculoskeletal complications, rehabilitation and psychosocial aspects. Males are more commonly affected than females during adolescence; however, as the age at injury decreases, the preponderance of males becomes less marked, and by 3 years of age the number of females with SCIs equals that of males. The neurologic level and degree of completeness varies with age; among children injured prior to 12 years of age approximately two-thirds are paraplegic and approximately two-thirds have complete lesions. Among adolescents, approximately 50% have paraplegia and 55% have complete lesions. Management of pediatric-onset SCI should be family centered and developmentally based, responsive to the dynamic changes that occur during growth and development. Distinctive anatomical and physiological features of children and adolescents, along with growth and development, are responsible for unique manifestations and complications of pediatric SCI. SCI without radiological abnormalities (SCIWORA), birth injuries, lap-belt injuries, upper cervical injuries, and the delayed onset of neurological deficits are relatively unique to pediatric SCI. Children who sustain their SCI before puberty experience a higher incidence of musculoskeletal complications, such as scoliosis and hip dislocation.
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Kelly EH, Mulcahey MJ, Klaas SJ, Russell HF, Anderson CJ, Vogel LC. Psychosocial outcomes among youth with spinal cord injury and their primary caregivers. Top Spinal Cord Inj Rehabil 2012; 18:67-72. [PMID: 23459120 PMCID: PMC3584752 DOI: 10.1310/sci1801-67] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Past research has found youth with disabilities to experience poor psychosocial outcomes, but little is known about factors related to psychosocial health among youth with spinal cord injury (SCI). OBJECTIVE To describe psychosocial health among youth with SCI, examine relationships between psychosocial outcomes and demographic and injury-related factors, and examine relationships between aspects of psychosocial health. Youth activity, participation, quality of life (QOL), coping, anxiety and depression, and caregiver mental health were included. METHODS Data were collected as part of a prospective study of 420 youth with SCI ages 1-18 and their primary caregivers. Activity data were also presented from a study developing a computerized adaptive testing (CAT) platform with 226 youth with SCI ages 8-21. RESULTS Although relationships varied by factor, youth outcomes were related to youth age, sex, age at injury/injury duration, and level/extent of injury. Caregiver mental health related to child age and age at injury. Further, relationships were uncovered between aspects of psychosocial health: aspects of youth mental health were related to youth participation and QOL, youth coping was related to youth mental health, participation, and QOL, and caregiver mental health was related to child mental health and QOL. CONCLUSION Psychosocial outcomes relate to each other and vary by child and injury-related factors and should be understood in a comprehensive, developmental context. Identifying best measures of activity and psychosocial functioning among youth with SCI and understanding factors related to their psychosocial health is critical to improving outcomes for the pediatric-onset SCI population.
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Calhoun CL, Mulcahey MJ. Pilot study of reliability and validity of the Walking Index for Spinal Cord Injury II (WISCI-II) in children and adolescents with spinal cord injury. J Pediatr Rehabil Med 2012; 5:275-9. [PMID: 23411768 DOI: 10.3233/prm-2012-00224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The objective of this study was twofold: 1) to evaluate the reliability of the Walking Index for Spinal Cord Injury II (WISCI-II) and Spinal Cord Independence Measure (SCIM) indoor mobility item (#12) when used with children with spinal cord injury (SCI) and 2) to examine the concurrent validity between the WISCI-II and the SCIM indoor mobility item in children with SCI. METHODS A convenience sample of 10 children with SCI between 4-16 years of age was recruited to complete 2 videotaped trials of ambulation for 10 meters. Six licensed physical therapists trained in the use of the WISCI-II and SCIM served as raters; each rater independently scored the WISCI-II and SCIM indoor mobility item for each of the subjects' two trials by reviewing the videotape. The viewing and scoring of Trial 1 and Trial 2 were separated by at least 3 weeks. Inter- and intra-rater reliability was calculated using Intraclass Correlation Coefficients (ICC) and 95% Confidence Intervals (CI). Concurrent validity was evaluated using the Spearman Correlation Coefficient (r<formula>_{s}</formula>). RESULTS Intra-rater and inter-rater reliability of repeated WISCI-II scores was high (ICC=0.98, CI=0.95-0.99; ICC=0.97, CI=0.96-0.99, respectively). Intra- and inter-rater reliability for the SCIM mobility score was equally high (ICC=0.96, CI=0.95-0.98, ICC=0.97, CI=0.95-0.98). There was strong correlation between WISCI-II scores and the SCIM indoor mobility item (r<formula>_{s}</formula>=0.99). CONCLUSION In this sample of 10 children and six trained raters, intra- and inter-rater reliability of WISCI-II scores and the SCIM mobility indoors scores was high, providing preliminary indication for their utility with children. The high correlation between the WISCI-II and SCIM mobility item further supports concurrent validity.
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Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey MJ, Schmidt-Read M, Waring W. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med 2011; 34:535-46. [PMID: 22330108 PMCID: PMC3232636 DOI: 10.1179/204577211x13207446293695] [Citation(s) in RCA: 1518] [Impact Index Per Article: 116.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Betz RR, Chafetz RS, Vogel LC, Samdani AF, Mulcahey MJ. Description of sensory preservation in children and adolescents with incomplete spinal cord injury. J Spinal Cord Med 2011; 34:297-300. [PMID: 21756568 PMCID: PMC3127374 DOI: 10.1179/2045772311y.0000000009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND/OBJECTIVE This cross-sectional, multicenter cohort study describes patterns of preserved sensation in persons with American Spinal Injury Association (ASIA) Impairment Scale (AIS) B (sensory incomplete, or SI) and AIS C/D (motor incomplete, or MI). METHODS A total of 93 subjects with incomplete spinal injuries (58 with tetraplegia and 35 with paraplegia) were included for analysis. Sensation was based on the International Standards for Neurological Classification of SCI (ISNCSCI). RESULTS In the 44 subjects with AIS B (SI), some light touch (LT) was present in 35% of dermatomes below the neurological level and pin prick (PP) in 8%. In contrast, in the 49 subjects with AIS C/D (MI), LT was present in 77% of dermatomes and PP in 27%. AIS C/D (MI) subjects with tetraplegia had more dermatomes with preserved sensation than those with paraplegia. When reviewing areas at highest risk for pressure sores, only 4 of 22 (19%) of subjects with AIS B (SI)/tetraplegia had any preserved LT or PP sensation in the periscapular region (dermatomes T1-T6). In the buttocks region (S3 and S4-S5), sensation was preserved in fewer than 50% of patients with either tetraplegia or paraplegia. CONCLUSIONS (1) Sensory sparing below the neurologic injury was found to be surprisingly sparse in patients classified as AIS B (SI) (35% LT and 8% PP). Sparing was considerably better in patients who were AIS C/D (MI) (77% LT and 27% PP). (2) Preserved sensation in the periscapular region was very low in subjects with tetraplegia (19%) and was also low in the buttocks, with fewer than half of those classified as AIS B (SI) with either tetraplegia or paraplegia reporting sensation.
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Flynn JM, Ramirez N, Emans JB, Smith JT, Mulcahey MJ, Betz RR. Is the vertebral expandable prosthetic titanium rib a surgical alternative in patients with spina bifida? Clin Orthop Relat Res 2011; 469:1291-6. [PMID: 20941646 PMCID: PMC3069281 DOI: 10.1007/s11999-010-1620-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Nonambulatory children with myelodysplasia are most likely to develop spinal deformity. As the deformity progresses, the overall health of the patient deteriorates. Traditional management of the deformity with fusion results in a short trunk, crankshaft deformity, and spine and lung growth inhibition. One alternative that potentially minimizes these problems is the vertebral expandable prosthetic titanium rib (VEPTR). QUESTIONS/PURPOSES We therefore asked whether the use of the VEPTR in immature nonambulating children with myelodysplasia with spinal deformity would (1) correct deformity; (2) allow growth; and (3) allow adequate respiratory function. PATIENTS AND METHODS We identified 20 nonambulatory patients with myelodysplasia who were part of a multicenter Investigational Device Exemption study of 214 patients treated with the VEPTR system. Demographics, standard radiographic measurements, pulmonary function parameters, and complications in 16 patients were analyzed. Average age at first surgery was 48.6 months. The minimum followup was 25 months (mean, 59 months; range, 25-164 months). RESULTS The Cobb angle decreased postoperatively in nine patients, increased less than 10° in five patients, and increased less than 20° in two patients. The mean increase in thoracic spinal length (growth) by year after the initial procedure with lengthening was 0.48 cm. Ventilatory function improved in 11 patients and deteriorated in five patients. Intraoperative complications occurred in two patients. Complications directly related to the implant were seven infections and five implant migrations. CONCLUSIONS Our observations suggest VEPTR is a reasonable treatment option for spinal deformity in the immature, nonambulatory myelodysplasia population correcting the spinal deformity, allowing spinal growth, and maintaining adequate respiratory function. The rate of complications is within the range reported for spinal fusion using standard approaches.
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Lauer RT, Smith BT, Mulcahey MJ, Betz RR, Johnston TE. Effects of cycling and/or electrical stimulation on bone mineral density in children with spinal cord injury. Spinal Cord 2011; 49:917-23. [PMID: 21423253 DOI: 10.1038/sc.2011.19] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Randomized clinical trial. OBJECTIVES To determine the effect of cycling and/or electrical stimulation on hip and knee bone mineral density (BMD) in children with spinal cord injury (SCI). SETTING Children's hospital specializing in pediatric SCI. METHODS A total of 30 children, aged 5-13 years, with chronic SCI were randomized to one of three interventions: functional electrical stimulation cycling (FESC), passive cycling (PC), and non-cycling, electrically stimulated exercise (ES). Each group exercised for 1 h, three times per week for 6 months at home. The hip, distal femur and proximal tibia BMD were examined via dual-energy X-ray absorptiometry (DXA) pre- and post-intervention. RESULTS In all, 28 children completed data collection. The FESC group exhibited increases in hip, distal femur and proximal tibia BMD of 32.4, 6.62 and 10.3%, respectively. The PC group exhibited increases at the hip (29.2%), but no change at the distal femur (1.5%) or proximal tibia (-1.0%). The ES group had no change at the hip (-0.24%) and distal femur (3.3%), but a loss at the proximal tibia (-7.06%). There were no differences between groups or within groups over time. Significant negative correlations were found between baseline BMD and the amount of BMD change. CONCLUSION Although not achieving statistical significance, hip BMD changes observed were greater than the reported 0.9-10% gains after exercise for children with and without disability. Thus, cycling with and without electrical stimulation may be beneficial for skeletal health in pediatric SCI, but further research is needed with a larger sample size.
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