Danielle Sandella

Sleep and quality of life in children with cerebral palsy

OBJECTIVE To examine the associations between sleep problems and quality of life (QoL) in children with cerebral palsy (CP). METHODS Prospective correlational study using parent-report forms to measure QoL and sleep disorder symptoms. Two groups comprised of 41 children with CP and 91 typically developing (TD) controls age 8-12years participated in a prospective correlational study. RESULTS Measures were the PedsQL-4.0 Generic scales and the Pediatric Sleep Questionnaire, with subscales of interest including sleep disordered breathing (SDB), excessive daytime sleepiness (EDS), insomnia (INS) and snoring (SNOR). Hierarchical regression analyses indicated that EDS contributed unique variance in physical QoL, and INS contributed unique variance in psychosocial QoL in children with CP; for TD children, sleep disorder symptoms were infrequent and not associated with physical or psychosocial QoL. CONCLUSIONS Findings highlight the importance of assessing sleep difficulties when addressing the needs of children with CP.

ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study.

Study Design. Delphi. Objective. The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS). Summary of Background Data. LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians. Methods. Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting. Results. A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated. The six top items were “leg or buttock pain while walking,” “flex forward to relieve symptoms,” “feel relief when using a shopping cart or bicycle,” “motor or sensory disturbance while walking,” “normal and symmetric foot pulses,” “lower extremity weakness,” and “low back pain.” Significant change in certainty ceased after six questions at 80% (P < .05). Conclusion. This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of “seven history items” that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes. Level of Evidence: 2

Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study

Study Design. Delphi. Objective. The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS). Summary of Background Data. LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians. Methods. Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting. Results. A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated. The six top items were “leg or buttock pain while walking,” “flex forward to relieve symptoms,” “feel relief when using a shopping cart or bicycle,” “motor or sensory disturbance while walking,” “normal and symmetric foot pulses,” “lower extremity weakness,” and “low back pain.” Significant change in certainty ceased after six questions at 80% (P < .05). Conclusion. This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of “seven history items” that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes. Level of Evidence: 2

Defining the Clinical Syndrome of Lumbar Spinal Stenosis: A Recursive Specialist Survey Process

Lumbar spinal stenosis has evolved from an anatomic concept to a poorly defined clinical syndrome. Rules for such a syndrome need to be informed by the experience and beliefs of expert clinicians. The level of certainty is seldom considered in defining criteria for a syndrome.

Symmetry of paraspinal muscle denervation in clinical lumbar spinal stenosis: Support for a hypothesis of posterior primary ramus stretching?

Denervation of the paraspinal muscles in spinal disorders is frequently attributed to radiculopathy. Therefore, patients with lumbar spinal stenosis causing asymmetrical symptoms should have asymmetrical paraspinal denervation.

Spinal stenosis: Factors that influence patients' decision to undergo surgery

Study Design:Prospective noninterventional observation. Objective:To examine factors that influence a patient’s real decision to accept the offer of surgery for lumbar spinal stenosis in a relatively controlled situation. Summary of Background Data:A patient’s decision to undergo spine surgery might be influenced by factors other than pathology. However, there is limited research exploring the decision. Methods:A study performed for other purposes recruited persons aged 55–90 years with medical record evidence of an offer of surgery for spinal stenosis by a university faculty surgeon. Inclusion criteria included neurogenic claudication, subjectively positive imaging, and difficulty walking 200 yards. Potential subjects with additional disabling conditions (eg, lower limb amputation), conditions that might mimic stenosis (eg, polyneuropathy), or some contraindications to invasive treatment (eg, anticoagulation) were excluded. Subjects filled out questionnaires on function, quality of life, pain, and health, and were examined by a spine surgeon masked to diagnostic category (Other recruits had back pain or no symptoms). Telephone follow-up 6–12 months later determined whether surgery was done. Results:Of 39 qualifying subjects, 20 followed through with surgery. A binary logistic regression revealed that significant factors that influence patient decision making included SF-36 measures of “Comparative Health” and “Role Limit Emotional” as well as the subject’s overall perception of their quality of life. The combination of all 3 factors yielded a predictive model (P=0.031). Individually, however, only “Comparative Health” was significant and able to predict a decision to proceed with surgery (P=0.036). Conclusions:In this population with significant disability, uncomplicated medical history, and a relatively clear diagnosis, the decision to accept surgical intervention was influenced by issues of perceived overall health and quality of life. Interventions to change real or perceived overall health may impact patient acceptance of surgery.

Patient perception of pain versus observed pain behavior during a standardized electrodiagnostic test

Introduction: Clinicians often assume that observations of pain behavior are adequate for assessment of patient pain perception during procedures. This has not been tested during a standardized electrodiagnostic experience. Methods: During a prospective trial including extensive, standardized electrodiagnostic testing on persons with lumbar stenosis, vascular claudication, and asymptomatic volunteers, the subjects and an observer rated levels of pain. Results: In 60 subjects, observers significantly under‐rated pain (Visual Analog Scale 3.17 ± 2.23 vs. 4.38 ± 2.01, t = −4.577, df = 59, P < 0.001). Perceived pain during testing related to bodily pain as measured by the visual analog, McGill, Pain Disability, and Quebec scales, but not age, duration of symptoms, Tampa kinesiphobia, Center for Epidemiological Studies Depression scale, or SF‐36 health quality of life. Conclusions: Persons with worse pain syndromes may perceive more pain during testing than others. Clinicians and researchers should understand that patients may have more pain than they recognize. Muscle Nerve 51: 185–191, 2015

Poster 153 Inter-Rater Reliability of Physiatrists in Diagnosing Neurogenic Claudication Under an Unconstrained Clinical Situation

tion of the left shoulder and marked atrophy of the left supraspinatus and infraspinatus. Patient was referred for a course of physical therapy in addition to diagnostic work-up. MRI of the left shoulder was significant for unilateral fatty infiltration and atrophy of the supraspinatus muscle without rotator cuff pathology. MRI of the cervical spine showed multilevel spondylitic foraminal narrowing at C3-5 on the left, and C6-7 bilaterally. Multiple nerve conduction studies and EMGs were performed in order to assess course and severity. Findings were consistent with incomplete denervation of the suprascapular. Radiographs, CT arthrogram, MRI and ultrasound of left shoulder failed to show an anatomic lesion as a cause for mononeuropathy. Due to worsening symptoms and loss of function despite physical therapy, patient was taken to the operating room for left open suprascapular nerve decompression with epineurolysis and open release of the transverse ligament. Setting: Sports medicine clinic. Results or Clinical Course: On 4-week postoperative visit, patient’s pain had resolved, left shoulder strength had improved (4/5 on MMT). Discussion: The “bowstring effect” during repetitive overhead activities is a pathophysiologic mechanism proposed for isolated suprascapular nerve injury in the absence of compressive pathology (ie, mass, cyst) as previously described. Conclusions: Prompt surgical release may be a necessary intervention in preventing permanent disability and functional recovery despite lack of findings on imaging.

Poster 155 Characteristics of Persons With Clinical Lumbar Stenosis in Comparison With Age-Matched Back Pain and Asymptomatic Volunteers

Disclosures: A. J. Haig, Ownership or partnership: Haig et al., Consulting LLC; Non-remunerative positions of influence, The International Rehabilitation Forum; The International Society for Physical and Rehabilitation Medicine; Non-remunerative positions of influence; The University of Michigan. Objective: While reversal of pathophysiology and improvement in capacity are important intermediate goals of many medical, surgical, and rehabilitation interventions, the improvement of actual participation in the community is the ultimate goal for most patients. Activity monitors can now measure daily walking participation. Since the principal impairment from neurogenic claudication is walking the current study hopes to examine factors that impact the ratio of walking participation:capacity (P:C) in that population and control groups. Variation in P:C ratio may disclose barriers to full participation that are psychological or social. Design: Prospective, controlled, NIH-funded trial. Setting: University clinic. Participants: Persons age 50-85 with clinician-diagnosed mechanical back pain, neurogenic claudication, and asymptomatic volunteers. Interventions: 6-minute walk test (capacity), 7 day activity monitor (participation), masked physical examination, multiple standardized surveys. Main Outcome Measures: Relationship of variables to the P:C ratio, defined as (average daily steps on activity monitor )/( steps taken during the 6 minute walk test). Results: 29 claudicants, 27 mechanical back pain and 33 asymptomatic volunteers completed the trial, with P:C ratios of 9.7 (s.d. 7.3), 9.3 (s.d. 3.9) and 10.7 (s.d. 5.6), respectively. The P:C ratio did not relate (P .05) to medical issues (diagnosis, visual analog pain, Pain Disability Index, McGill, obesity, age, sex), psychosocial issues (education, Tampa kinesiphobia scale, CESD Depression scale) or any SF-36 quality of life component. Conclusions: Surprisingly this extensive evaluation did not find factors that relate to optimization or diminution of participation, given a certain level of disability. In a larger group, in other populations, or in other diseases, parameters that alter the P:C ratio might help guide rehabilitation.