Kathryn (Katie) Lucas

Objective: To evaluate hospital outcomes of surgical corrections of spinal deformity in children with spinal cord injury (SCI). Study design: Cross-sectional study. Setting: National Inpatient Sample (1998-2021) was used to identify in-hospital outcomes of spinal fusion for spinal deformity. Participants: 768 children (0-17) with SCI. Interventions: Not applicable. Outcomes Measures: Critical care intervention (CCI) complications, hospital length of stay, charges, and discharge disposition. Individual and hospital characteristics were noted. Results: Average age 14 (SD = 6), 48% females, 65% non-Hispanic White. Most cases were incomplete-SCI (38% thoracic, 31% cervical). Most surgeries occurred in large (66%) and urban teaching (93%) hospitals. A quarter received CCI and 43% developed complications. Median length of stay was 8 days (interquartile range: 5-14) and median charges were $230,136 (interquartile range: $150,131-$356,481). Mortality was low (<2%) and 41% were discharged to home healthcare or a medical facility. Having three or more comorbidities was associated with worse outcomes. Children on Medicaid were more likely to receive CCI. Older age, comorbidities, income, injury completeness, and bone fracture increased the likelihood of discharge to more care. Conclusion: Spinal fusion for spinal deformity in children with SCI results in significant morbidity, prolonged hospital stays, substantial charges, and frequent post-discharge care. These findings underscore the significant healthcare burden and morbidity associated with spinal fusion for spinal deformity in children with SCI, emphasizing the need for optimized perioperative management and long-term follow-up. Future research should evaluate longitudinal outcomes. Altogether, it would guide restorative programs aiming to prevent or slow deformity progression.

Paralysis is assumed permanent in persons with motor-complete spinal cord injury (SCI). However, spinal epidural stimulation combined with activity-based locomotor training (ABLT) and cognitive intent enabled two adults with motor-complete SCI to walk with a walker. Transcutaneous spinal stimulation (scTS), also capable of promoting a cyclic step-like pattern, might be a viable alternative in children with SCI. These findings prompted our investigation into multimodal neuromodulation training using ABLT (enhancing afferent input), spinal stimulation (scTS), and descending (intent) drive to restore voluntary stepping in children with chronic motor-complete SCI. Five non-ambulatory children (9.6 ± 2.5 years old, 3F, 4 thoracic/1 cervical injury) with chronic (>1 year, 5.2 ± 2.5 years), complete SCI underwent 60 sessions of combined ABLT and scTS training with cognitive intent to step and returned for a 3 to 6-month follow-up. During the first training session in a gravity-neutral position, all five children (5/5) made small reciprocal cycles of the hips/knees in a flexion/extension step-like pattern with stimulation, with increased excursion at session 20 for 5/5 children (right hip excursion increased from 10.1 ± 15.1 to 25.9 ± 21.3 degrees and right knee excursion increased from 9.3 ± 13.9 to 39.6 ± 29.2 degrees, p = 0.02). The children stepped overground at session 50 (P15), 60 (P34), and 20 (P32, P14, P240), voluntarily initiating and alternating left/right leg swings on the treadmill and overground with and without scTS. Three to six months post-training, all children maintained the capacity to step. The parents and children reported unanticipated improvements in sensation, bladder function, proprioception, assist to stand, transfers, and dressing. In children with chronic, motor-complete SCI, multimodal neuromodulation training can potentiate the intrinsic stepping capacity of the spinal locomotor centers to enable voluntary stepping. Remarkably, these enhancements are durable and observed even in the absence of spinal stimulation.

Background: Blood flow restriction training (BFRT) is a popular rehabilitation intervention after anterior cruciate ligament reconstruction (ACLR). However, there are a lack of clinical trials establishing the efficacy of using BFRT during rehabilitation to improve quadriceps muscle function. Purpose: The purpose of this study is to evaluate the efficacy of blood flow restriction training to improve quadriceps muscle strength, morphology, and physiology, and knee biomechanics in individuals after ACLR in a double-blind, randomized, placebo-controlled clinical trial (NCT03364647). Methods: Forty-eight athletes (20 females/28 males) were randomly assigned to low-load strength training with active BFRT or standard of care strength training with a sham unit. Treatment occurred for 1-month pre-surgery and 4 to 5 months post-surgery with both groups following the same standard rehabilitation protocol. Outcome variables were measured at baseline and 4 to 5 months post-surgery. Quadriceps muscle strength (isometric and isokinetic peak torque and rate of torque development) was measured on an isokinetic dynamometer. Quadriceps muscle morphology (physiological cross-sectional area, fibrosis) was determined using magnetic resonance imaging. Quadriceps muscle physiology (fiber type, fiber cross-sectional area, satellite cell abundance, collagen content, fibrogenic/adipogenic progenitor cells) was evaluated with muscle biopsies of the vastus lateralis. Knee extensor moment and knee flexion angle were measured via three-dimensional gait analysis. Change scores were calculated as: post-intervention - baseline. Two-sample t-tests were then used to assess between-group differences for each outcome variable. Results: No significant between-group differences were found for any outcome variable. Conclusions: The addition of BFRT to a rehabilitation program for athletes pre- and post-ACLR was no more effective than standard rehabilitation for improving quadriceps muscle function. Clinicians should consider the value of BFRT relative to the cost, time, and discomfort for patients in light of these results. Copyright © 2024 by the American College of Sports Medicine.

Objective: In adults with cervical spinal cord injury (SCI), transcutaneous spinal stimulation (scTS) has improved upper extremity strength and control. This novel noninvasive neurotherapeutic approach combined with training may modulate the inherent developmental plasticity of children with SCI, providing even greater improvements than training or stimulation alone. Because children with SCI represent a vulnerable population, we first must establish the safety and feasibility of any potential novel therapeutic approach. The objectives of this pilot study were to determine the safety, feasibility, and proof of principle of cervical and thoracic scTS for short-term effect on upper extremity strength in children with SCI. Materials and Methods: In this nonrandomized, within-subject repeated measure design, seven participants with chronic cervical SCI performed upper extremity motor tasks without and with cervical (C3–C4 and C6–C7) and thoracic (T10–T11) site scTS. Safety and feasibility of using cervical and thoracic sites scTS were determined by the frequency count of anticipated and unanticipated risks (eg, pain, numbness). Proof-of-principle concept was tested via change in force production during hand motor tasks. Results: All seven participants tolerated cervical and thoracic scTS across the three days, with a wide range of stimulation intensities (cervical sites = 20–70 mA and thoracic site = 25–190 mA). Skin redness at the stimulation sites was observed in four of 21 assessments (19%) and dissipated in a few hours. No episode of autonomic dysreflexia was observed or reported. Hemodynamic parameters (systolic blood pressure and heart rate) remained within stable limits (p > 0.05) throughout the assessment time points at baseline, with scTS, and after the experiment. Hand-grip and wrist-extension strength increased (p < 0.05) with scTS. Conclusions: We indicated that short-term application of scTS via two cervical and one thoracic site is safe and feasible in children with SCI and resulted in immediate improvements in hand-grip and wrist-extension strength in the presence of scTS. Clinical Trial Registration: The Clinicaltrials.gov registration number for the study is NCT04032990. © 2023 The Authors

Neuromodulation via spinal stimulation is a promising therapy that can augment the neuromuscular capacity for voluntary movements, standing, stepping, and posture in individuals with spinal cord injury (SCI). The spinal locomotor-related neuronal network known as a central pattern generator (CPG) can generate a stepping-like motor output in the absence of movement-related afferent signals from the limbs. Using epidural stimulation (EP) in conjunction with activity-based locomotor training (ABLT), the neural circuits can be neuromodulated to facilitate the recovery of locomotor functions in persons with SCI. Recently, transcutaneous spinal stimulation (scTS) has been developed as a noninvasive alternative to EP. Early studies of scTS at thoracolumbar, coccygeal, and cervical regions have demonstrated its effectiveness in producing voluntary leg movements, posture control, and independent standing and improving upper extremity function in adults with chronic SCI. In pediatric studies, the technology of spinal neuromodulation is not yet widespread. There are a limited number of publications reporting on the use of scTS in children and adolescents with either cerebral palsy, spina bifida, or SCI. ©2023 American Spinal Injury Association.

Incomplete spinal cord injuries (ISCI) in pediatrics and adults can lead to asymmetric motor impairments exhibiting as asymmetries of posture and gait. Recently, rehabilitation guidelines for adults with neurologic injuries have focused on gaining a functional gait pattern as measured by speed and distance, even if asymmetry deficits persist. Activity-based restorative therapies (ABRT) take advantage of activity-dependent neuroplasticity to change an individual’s neuromuscular capacity. This is a report of an ambulatory child with chronic ISCI presenting with significant postural and gait asymmetries who enrolled in an ABRT program. Across 79 ABRT sessions, the child gained symmetry during sitting, standing, and walking. Even though this child was a functional ambulator at enrollment, targeting symmetry of movements via improved neuromuscular capacity further enhanced her achievement of kinematically appropriate function for participation in daily activities. © 2023 by the authors.

Background: A recent study in pediatric spinal cord injury (SCI) demonstrated activity-based locomotor training (ABLT) improved trunk control, measured by the Segmental Assessment of Trunk Control (SATCo). It is not known whether improved trunk control is maintained and, if so, for how long. Objectives: The purpose was to determine the durability of improvements in trunk control after ABLT is stopped. We hypothesized that SATCo scores at follow-up would not significantly regress (a) beyond the score measured at discharge and (b) to the initial SATCo pre-ABLT level. Methods: Patients were assessed pre ABLT, after completing an episode of care, and upon returning to the clinic 1 or more months without ABLT. Durability is a score change less than 3, which is the measurement error of the SATCo. Results: Twenty-eight children (10 females; 4 ± 2.5 years old) completed at least 40 sessions of ABLT and returned for the follow-up 8 ± 7 months (range, 1-38) after the episode of care. Trunk control improved 6 ± 3/20 points with ABLT (p < .0001). At the follow-up, average SATCo score decreased 2 ± 2/20 points, and the follow-up SATCo score was 4 ± 3 points higher than pre ABLT (p < .0001). There was no correlation between the change in SATCo scores and changes in age, weight, height or elapsed time between discharge and follow-up. Conclusion: Improvements in trunk control due to ABLT were maintained, indicating ABLT is neurotherapeutic. Although not achieving complete recovery of trunk control, the immediate effects and sustained improvements provide support for a clinical shift to neurotherapeutic approaches and for continued research to achieve enhanced recovery. © 2022 American Spinal Injury Association.

Postoperative management of anterior cruciate ligament (ACL) reconstruction has traditionally focused on the evaluation and intervention of musculoskeletal components such as range of motion and patients’ reports of function. The integumentary system can provide early indications that rehabilitation may be prolonged due to protracted or poor healing of the incision sites. Full evaluation of the reconstruction over time, including direction of the incisions, appearance of surgical sites, level of residual innervation, and health of the individual should be considered when determining time-based goals and plans for returning an athlete to activity. Skin care techniques should be used to minimize strain and promote wound healing at the surgical sites, which in turn allows for implementation of other interventions that target other body systems such as locomotion, strength training, and cardiopulmonary conditioning. The integration of the integumentary system with cardiovascular, neurological, and muscular systems is required for a successful return to activity. A multi-physiologic systems approach may provide a unique viewpoint when aiming to attain a greater appreciation of the integumentary system and its integration with other body systems following ACL reconstruction. The purpose of this clinical commentary is to discuss integumentary considerations within a multi-physiologic systems approach to human movement after ACL reconstruction, including an anatomical review, key elements of assessment, and integrated intervention strategies. Level of Evidence 5. © 2022, North American Sports Medicine Institute. All rights reserved.

Postoperative rehabilitation of anterior cruciate ligament (ACL) reconstruction mainly focuses on the restoration of strength and range of motion with a long-term goal to return athletes to their prior level of activity. Of those wanting to return to sport, many are either unable and/or experience protracted recovery despite extensive rehabilitation. To holistically care for patients recovering from ACL reconstructions, reframing rehabilitation to consider a comprehensive systems approach (including musculoskeletal, cardiovascular, endocrine, and neurologic systems) may help improve treatment outcomes. The American Physical Therapy Association has adopted a vision statement that embraces the concept of a ‘movement system,’ but validation of the movement system has been challenging. Application of a multi-physiologic systems approach may provide a unique perspective to better understand the nervous system and its interactions after ACL reconstruction. The purpose is to focus on the nervous system contributions to a multi-physiologic system approach to rehabilitation from ACL reconstruction. Level of Evidence 5. © 2022, North American Sports Medicine Institute. All rights reserved.

Objective:To determine the relationship between patient-reported outcomes (PROs) to the single-leg step-down test (SLSD) and the Y-balance anterior reach (YB-A) 6 months after primary anterior cruciate ligament reconstruction (ACLR).Design:Cross-sectional.Setting:Laboratory.Participants:Sixty-six patients 6 months after ACLR participated.Interventions:Patients performed the SLSD, YB-A, and completed PROs after ACLR.Main Outcome Measures:Patients completed the International Knee Documentation Committee Score (IKDC), the Lysholm Activity Scale, the Tampa Scale of Kinesiophobia (TSK-11), and the Knee Injury and Osteoarthritis Outcome Score (KOOS)-Symptom, -Sport, and -Quality of Life (QOL) subscales. The SLSD requires subjects to complete as many single-leg step-downs as possible in 60 seconds, and the YB-A involves reaching anteriorly on a single limb. Pearson product moment correlations were used to assess relationships between the YB-A and SLSD performance to each PRO.Results:Single-leg step-down test symmetry was significantly correlated with the TSK-11 (r = -0.70), KOOS-Sport (r = 0.40), -Symptom (r = 0.46), and -QOL (r = 0.42). The YB-A symmetry was significantly correlated with the KOOS-Symptom (r = 0.30) and KOOS-Sport (r = 0.30).Conclusions:Single-leg step-down test performance demonstrated stronger relationships to patient-reported knee function than the YB-A. Furthermore, the SLSD symmetry was strongly correlated with fear of movement. The SLSD provides a robust method for clinicians to assess dynamic knee function and may aid in identifying patients who could benefit from intervention to reduce fear of movement or reinjury. © 2021 Lippincott Williams and Wilkins. All rights reserved.