Pamela E. Wilson

Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population

Athletic concussion is a growing focus of attention for pediatricians. Although numerous literature reviews and clinical guidelines are now available pertaining to athletic concussion, few have focused on the pediatric athlete in particular. Sport-related concussions occur relatively frequently in children and adolescents, and primary health care providers are often responsible for coordinating clinical management. Here we summarize the scientific literature pertinent to the care of young athletes. We examine how concussion affects younger and older athletes differently at biomechanical, pathophysiological, neurobehavioral, and contextual levels. We also discuss important issues in clinical management, including preparticipation assessment, concussion evaluation and recovery tracking, and when and how to return pediatric athletes to play sports. We also briefly cover non–sport-related interventions (eg, school support). With proper management, most children and adolescents sustaining a sport-related concussion can be expected to recover fully.

Pediatric Spinal Cord Tumors and Masses

Abstract Background/Objective: Spinal cord tumors are a relatively rare diagnosis, accounting for 1% to 10% of all pediatric central nervous system tumors. Understanding the etiology and clinical outcomes of these tumors is therefore very important. This study presents detailed information regarding clinical presentation, histological findings, outcomes, functional assessment, and management of a series of patients with this diagnosis. Method: Retrospective, descriptive study. Subjects: Thirty-five children with a final diagnosis of spinal cord tumor or mass, excluding dysraphism. Results: Neurodevelopmental tumors (dermoid tumors, epidermoid tumors, and teratomas) were the most common tumor type (31 %), followed by astrocytomas (29%) and neuroblastomas (14%). Other types included schwannomas, meningiomas, giant cell tumors, extradural cystic masses, leukemic-related masses, and masses related to neurofibromatosis. Mean age at diagnosis was 6.6 years (SD = 5.5 y) and did not vary significantly by tumor type except for children with neuroblastoma (mean = 0.4 y, SD = 0.5 y). More boys (57%) were identified in the series than girls (43%); however, there was no association between tumor type and sex. Presenting complaints of pain were noted in 57% and were localized to the back, neck, or extremities. Extremity weakness was reported as an initial presenting symptom in 46%. Three children had scoliosis as a presenting issue and 14 had gait abnormalities. Regardless of treatment modality, mobility was retained in 83% of children with or without gait aids. Neurogenic bowel and/or bladder were present in 23% of the population. Conclusions: This study corroborates other studies indicating that intramedullary tumors are the predominant form of pediatric spinal cord tumor. This population, however, presented with an unusually large number of developmental tumors, contrary to several published studies. The disparity may be the result of this institution acting as a regional referral center, thus increasing the number of this type of patient. The population is too small to make any other conjecture. The predominance of astrocytomas and neuroblastomas among those patients with poor outcomes and the prevalence of developmental tumors suggest the need for broader investigation. Although, in general, spinal cord tumors are relatively rare, this preliminary study supports the need to further evaluate associations between tumor type, presenting symptoms, treatment, and functional outcome in children with spinal cord tumors.

Botulinum toxin type a in the treatment of children with congenital muscular torticollis.

Oleszek JL, Chang N, Apkon SD, Wilson PE: Botulinum toxin type A in the treatment of children with congenital muscular torticollis. Am J Phys Med Rehabil 2005;84:813–816. This is a retrospective case series describing the use of botulinum toxin type A in the treatment of children with congenital muscular torticollis who fail to progress with conservative management. A total of 27 children with congenital muscular torticollis, 6–18 mos of age, received 30 botulinum toxin type A injections into their sternocleidomastoid or upper trapezius muscle, or both, at a pediatric tertiary care center between 1995 and 2001. Three children received repeat injections. Twenty of 27 children (74%) had improved cervical rotation or head tilt after the injections, and 2 of 27 (7%) experienced transient adverse events, specifically, mild dysphagia and neck weakness. This series suggests that botulinum toxin type A may be a safe and effective treatment option for children with congenital muscular torticollis who are unresponsive to a traditional regimen of physical therapy and a home program. A prospective, randomized controlled trial is necessary to definitively assess the role of botulinum toxin type A in this population.

Sports and Disability

Participation in recreational and competitive sports at an early age has long been touted as a positive influence on growth and development, and for fostering lifelong healthy lifestyles. The benefits of an active lifestyle include not only fitness, but the promotion of a sense of inclusion and improved self‐esteem. These benefits are well documented in all populations, and their importance has been summarized in the recent Healthy People 2010 guidelines. The American Academy of Pediatrics has recently produced a summary statement on the benefits of activity for disabled children. They note that children with disabilities tend to have an overall lower level of fitness and an increased level of obesity. For this population, developing a lifelong desire to be active can be a simple means for limiting illness and much of the morbidity associated with sedentary lifestyles often associated with disability. For disabled youth, participation in disabled sports programs available nationally and internationally can be an effective means to promote such precepts. The goal of this focused review is to improve the learners knowledge of the positive impact that active lifestyles can have on overall health in the disabled youth population and, as a result, modify their practice by incorporating recreational and competitive sport activities as part of improving overall patient care.

Exercise and sports for children who have disabilities

This article focuses on the exercise needs of children who have disabilities, how these needs differ from able-bodied children, and what medical concerns are relevant for a given disability. The information presented also discusses some preventative options related to individual sports and a discussion of various organized recreational and competitive opportunities available both nationally and internationally. In addition, a listing of major disabled sports organizations is provided for reference.

A survey of chronic pain in the pediatric spinal cord injury population.

Abstract Background/Objective: Although several reports characterize pain associated with adult-onset spinal cord injury (SCI), little is known about the incidence and etiology of pain associated with pediatric-onset SCI. The purpose of this study was to assess the incidence and type of chronic pain in the pediatric SCI population and to evaluate the resulting impact on activities of daily living (ADLs). Methods: Patients attending clinic in a pediatric tertiary care facility in a major metropolitan area having sustained an SCI during childhood were asked to participate. Participants were assessed using the Adolescent Pediatric Pain Tool and the Lansky Play Performance Scale, 2 sta ndardized assessments of pain and function, respectively. ln addition, a questionnaire designed to characterize the population and the types of pain reported was administered. Results: Thirty-one participants were enrolled with an age range at the time of injury from 5 months to 18 years. Ofthis population, 65% reported chronic pain. The pain reports were classified as either nocioceptive ( 48%) or neuropathic (19%). lnterference with ADLs and play was present in only 1 participant. Conclusion: Based on these pilot data, pain associated with a pediatric-onset SCI is common. The incidence of pain in this study approached the reported incidence of chronic pain in adult-onset SCI. ln the present population, nocioceptive pain was more common than was neuropathic pain. These data suggest that although common, chronic pain associated with childhood SCI has a significantly smaller impact on daily activities than that reported in the Iiterature for adult-onset SCI.

Factors Associated with Mobility Outcomes in a National Spina Bifida Patient Registry

ObjectiveTo provide descriptive data on ambulatory ability and muscle strength in a large cohort of individuals with spina bifida enrolled in a National Spina Bifida Patient Registry and to investigate factors associated with ambulatory status. DesignCross-sectional analysis of data from a multisite patient registry. ResultsDescriptive analysis of mobility variables for 2604 individuals with spina bifida aged 5 and older are presented from 19 sites in the United States. Analysis of a subset of National Spina Bifida Patient Registry data from 380 individuals from 3 sites accompanied by data from a specialized spina bifida electronic medical record revealed that those with no history of a shunt, lower motor level, and no history of hip or knee contracture release surgery were more likely to be ambulatory at the community level than at the household or wheelchair level. ConclusionThis study is the first to examine factors associated with ambulatory status in a large sample of individuals with myelomeningocele and nonmyelomeningocele subtypes of spina bifida. Results of this study delineate the breadth of strength and functional abilities within the different age groups and subtypes of spina bifida. The results may inform physicians of the characteristics of those with varying ambulatory abilities. To Claim CME Credits:Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives:Upon completion of this article, the reader should be able to: (1) Understand the scope of mobility limitations in individuals with spina bifida; (2) Appreciate the impact of certain factors on themobility status of individuals with spina bifida; and (3) Use knowledge of factors affecting mobility in individuals with spina bifida to direct treatment. Level:Advanced Accreditation:The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The role of ethnicity and culture on functional status in children with spina bifida.

PURPOSE Spina bifida is a common cause of pediatric disability and more prevalent in the Hispanic population. Significant health disparities exist in minority populations. Culturally adapted health interventions have been attempted in conditions such as pediatric asthma with improvement. This study aims to explore the influence of ethnicity and culture with regards to functional status and care satisfaction. METHODS Study participants were recruited from the Childrens Hospital Colorado Spinal Defects Clinic. Demographics and past medical and surgical history were obtained via chart review. A questionnaire assessed ethnicity, acculturation, self-care, mobility, bowel and bladder function, and care satisfaction. RESULTS A total of 70 subjects with spina bifida were included in the statistical analysis. There was no difference in PEDI self-care and mobility scores between ethnicities. The Hispanic group had higher urinary incontinence rates, higher percentage with bladder accidents, and lower satisfaction with bladder management. Regarding bowel function, the Hispanic group had lower satisfaction rates and a trend towards lower bowel continence. CONCLUSIONS Further work is needed to understand the social and cultural differences between Hispanic and Non-Hispanic children and their families that impact bowel and bladder continence and care satisfaction. Once identified, culturally sensitive interventions may be implemented that can alleviate these apparent health disparities.

Concussion in Children and Adolescents

Pediatric concussion is a growing concern as children across the country become more involved in sports and are leading more active lifestyles. Mild traumatic injuries to the brain are common and can have varied clinical presentation ranging from minimal to severe symptomatology. The morbidity associated with these injuries usually resolves in a matter of weeks or becomes more protracted, causing significant disruption in lifestyle and quality of life. We explore here recent research addressing innovations in acute care, treatment of protracted concussive recovery (postconcussion syndrome), and the assessment of cognitive outcomes and their interpretation as well as new approaches to modeling recovery based on biochemical and neuroimaging biomarkers.

Poster 486: Marinol and the Treatment of Pediatric Agitation

Design: Prospective study on consecutive patients undergoing a fluoroscopically guided injection into the SIJ. Setting: Academic institution. Participants: Patients suspected given history and physical examination to have SIJ mediated pain. Interventions: 2 cc mixture of 1cc of 2% lidocaine and 1 cc of triamcinolone 40mg/mL was injected into the SIJ after correct needle placement was confirmed using contrast dye and real time fluoroscopy. Main Outcome Measures: An independent physician assessed pain score on 0-10 scale immediately before and after the injection, and at 2-4 weeks and 6 months after the injection. Results: 100% immediate pain relief was considered a positive anesthetic response, while 50% pain relief at follow-up was considered positive. 14/34 (41.0%, 95% CI 26.4-57.8%) obtained 100% immediate relief. 8/14 (57.1%, 95% CI 32.6-78.6%) that had 100% initial relief reported 50% relief at 2-4 weeks, and 5/8 (62.5%, 95% CI 30.6-86.3%) had 50% relief at 6 months. Of the 6/14 (42.9%, 95% CI 21.4-67.4%) that had an initial 100% pain relief, but did not achieve 50% pain relief at 2 weeks, 0/6 (0%, 95% CI 0-39.0%) had 50% pain relief at 6 months. Of those with a negative initial block, only 3/20 (15%, 95% CI 5.2-36.0%) had 50% pain relief at 2 weeks or 6 months. Conclusions: This study illustrates a high negative predictive value of the immediate response at predicting pain relief at 2-4 weeks, but a much stronger positive predictive value of pain at 2-4 weeks for predicting continued pain relief at 6 months. Level of Evidence: Level II