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Pediatric-Onset Rehabilitation

Cognitive Function

Children with SCI or myelopathy may be at risk of cognitive dysfunction. Little is known about the frequency of cognitive dysfunction post-SCI, its etiology, and which cognitive domains are most affected. Cognitive dysfunction may arise from concurrent traumatic brain injury, from the etiology causing myelopathy, such as demyelination or central nervous system inflammation, from systemic effects of treatment for the etiology of SCI such as chemotherapy, and other causes not well-elucidated (Harder et al. 2013; Zonfrillo et al. 2014). Studies characterizing cognitive dysfunction post-SCI or post-myelopathy are summarized in the Tables below.

Author, Year


Study Design

Sample Size



Outcome Measure


(Zonfrillo et al., 2014)



N=13,798 (2,952= SCI)

Population: Age: 7-18 yr. % Males by injury etiology: TBI=70.0%, Tetraplegia=77.7%, Paraplegia=73.7%, Other=58.4%.

Injury etiology: 1) TBI (n=6297); 2) tetraplegia (n=946); 3) paraplegia (n=1244); or 4) other (which included combinations of TBI and SCI, TBI and multiple fracture/ amputation, SCI and multiple fracture/amputation, burns, or other multi-trauma) (n=5311).

Intervention: None.

Outcome Measures: Functional Independence Measure (FIM) cognitive subscore.

1.         Subjects with tetraplegia and paraplegia as their main injury code had higher levels of cognitive functionality on admission compared with the TBI group.

2.        Median admission FIM cognitive subscore for those with tetraplegia or paraplegia was 6, and the majority of these patients improved to 7 on discharge.

3.        All injury groups demonstrated improvements in FIM cognitive subscores on discharge from rehabilitation (p<0.0001 for each); children with TBI had more severe discharge cognitive disability compared with those with SCI, burns, or multiple injuries.

4.        Subjects with SCI had longer length of stays than those without SCI (p<0.0001).

5.        When examining trends over time, there was an overall slight decrease in length of stay (median 15 days in 2002 [IQR 5-29] to median 13 days in 2011 [IQR 8-25 days], p=0.02).

6.        The discharge cognitive stages over time have remained stable (median 5 [IQR 4-6]) for 2002-2011.

(Harder et al., 2013)




Population: Age: 11.5±3.4 (5-18) yr; Gender: males=9, females=15; Injury etiology: Transverse Myelitis; Age of Onset: 9.7±4.8 (1-17) yr; Level of injury: cervical (N=13); Ambulation: normal=46%, abnormal but ambulated independently=79%, bilateral support (i.e., crutches) =29%, wheelchair-bound=8.3%.

Intervention: None. Neuropsychological evaluation, patient and caregiver surveys.

Outcome Measures: California Verbal Learning Test, Children’s Version (CVLT-C; 5–16 yr and 17-18 yr), Digit Span subtest from the Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV; 6–16 yr), Wechsler Adult Intelligence Scale, Third Edition (WAIS-III; 17–18 yr), Symbol Search sub­test from the WISC-IV/WAIS-IV, Symbol-Digit Modali­ties Test (SDMT; 8–18 yr), Oral Version, Beery Developmental Test of Visual-Motor Integration, Fifth Edi­tion (VMI-5; 5–18 yr), The Grooved Pegboard (5-18 yr), Trail-Making Test (TMT; 9–18 yr), Letter Fluency subtest from the Delis-Kaplan Executive Function System (DKEFS; 8–18 yr), Pediatric Quality of Life (PedsQL; 5–18 yr) Multidimensional Fatigue Scale, Behavior Assessment System for Children, Sec­ond Edition (BASC-2; 5–18 yr), Hauser Ambulation Index, school function, medication use.




Note: Mildly Impaired (≤1.0 SD from the mean or 16th percentile); Moderately Impaired (≤1.5 SD from the mean or 5th percentile); Severely Impaired (≤2.0 SD from the mean or 2nd percentile).


Fine Motor/Visual-Motor Skills

1.         For the non-dominant hand, mild deficits were observed in 45.5% of subjects, with severe deficits noted in 36.4%; for the dominant hand, mild, moderate, and severe deficits were revealed in 40.9%, 22.7%, and 13.6% of participants, respectively.

2.        For graphomotor (i.e., paper/pencil) skills, mild, moderate, and severe deficits in visual-motor integration were observed in 28.6%, 19%, and 4.8%, respectively.

3.        The lowest rate of impairment was observed in the area of visual perception (only 4.5% were mildly impaired, none were moderate or severe).


Attention and Executive Function

4.        Approximately 18.2% of participants showed moderate impairment in auditory attention and working memory (i.e., Digit Span), while 40.9% had at least a mild deficit.

5.        Parents reported “at-risk” or subclinical attention problems in approximately 30% of participants although no patients demonstrated severe problems in this area, nor did participants’ parents report clinically significant attention problems.

6.        While 5.6% of participants showed severe defi­cits in simple attention (i.e., Trail-Making Test A), 11.1% showed severe deficits in complex attention and sequenc­ing (i.e., Trail-Making Test B).

7.        Mild and moderate deficits were noted in the area of verbal fluency for 25% and 20% of the sample, respectively.


Verbal Memory

8.        Deficits in initial free recall (i.e., CVLT-C/II Trial 1) were mildly and moderately impaired at rates of 33.3% and 20.8%, respectively; rates of deficits in free recall decreased with opportuni­ties for rehearsal.

9.        Long delay free recall was mildly, moderately, and severely impaired in 25%, 8.3% and 4.2% of participants, respectively.


Processing speed

10.      Mild and moderate deficits in motor-based processing speed were observed at rates of 20% and 10%, respectively; however, when the motor component was removed, moderate and severe impairment were observed at rates of 10% and 5%, respectively.

Author, Year


Study Design

Population, Intervention, Outcome Measures

(Salvato et al., 2017)


Case Report


Population: 40 mo, female, complete C2 traumatic SCI.

Intervention: None. Neuropsychological assessment.

Outcome Measure: Body representation (“Matching Body Parts by Location”), intelligence (Matrix reasoning subtest of the “Wechsler Preschool and Primary Scale of Intelligence Third Edition”)


Only two studies have characterized the frequency and types of cognitive dysfunction post-SCI. Harder et al. (2013) evaluated cognition in children with transverse myelitis. Although transverse myelitis does not involve brain demyelination, more than half of patients had either mild (40.9%) or moderate (18.2%) attentional dysfunction, and nearly half of patients had mild (25%) or moderate (20%) reductions in verbal fluency, and more than half of patients had mild (33.3%) or moderate (20.8%) impairments in verbal memory. Abnormalities were also observed for processing speed and fine motor skills; however, much of this may be attributable to transverse myelitis and its impact on motor function rather than cognition. Zonfrillo et al. (2014) used a large observational database of children admitted for inpatient rehabilitation. Compared to children with traumatic brain injury, children with SCI (paraplegia and tetraplegia) had higher cognitive functioning at admission and at discharge from inpatient rehabilitation. More than half of children with paraplegia and tetraplegia improved to the highest Functional Independence Measure cognitive subscore on discharge. In a case report of a child with complete C2 tetraplegia, mental body representation was altered compared to age-matched controls (Salvato et al. 2017). 

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