TM and Cognitive Functioning

Transverse myelitis (TM) has been traditionally thought of as a condition that only affects the spinal cord, causing numbness, weakness, walking difficulty, bowel/bladder dysfunction and sometimes pain. Children affected by this condition often need accommodations at school based on physical limitations. These accommodations are required under federal law for individuals with disabilities and are necessary for such children to fully participate in the academic environment.

While cognitive problems in pediatric TM have been reported anecdotally, until now, these have not been systematically investigated. Along with my colleagues at the Transverse Myelitis Clinic located at the Children’s Medical Center of Dallas and University of Texas Southwestern Medical Center, we have recently published the first paper describing cognitive functioning in 24 pediatric patients between the ages of 5 and 18 diagnosed with idiopathic TM in the Multiple Sclerosis Journal. The average age of the children in the study was about 9.67 years and the children we enrolled in this study had normal brain MRIs. All children with TM were administered a neuropsychological battery and were assessed for emotional functioning, symptoms of fatigue, mobility and school performance. Although, as a group, scores generally fell within the average range, performance varied widely within specific domains of functions. Our study results suggest that in addition to fine-motor problems, children diagnosed with TM also exhibit difficulties in attention (in 40.9% of the study participants) and memory (in 33% of the study participants) and to a lesser extent, in the areas of processing speed and verbal fluency. About 30% of the parents also validated sub-clinical attention problems on standardized rating.

Do medication, mood, and/or fatigue play a role?
Given their potential impact on cognitive functioning, medication use, emotional functioning, and fatigue symptoms were examined. Approximately 46% of the children with TM were on some type of medication. Notably, 30% percent experienced at least some degree of symptoms associated with depression. Elevated symptoms of fatigue were common and were reported by both the children and their parents. Of note, however, the data suggested that neither medication nor mood played a role in cognitive functioning. Data suggests, however, that fatigue may plan an important role in cognitive functioning. Additional studies are needed to explore these variables in more depth. Such information provides important information for determining targeted treatment. This research also highlights the need for comprehensive evaluations and care for children affected by TM.

What are the implications?
Overall, although a small retrospective study, these findings have important implications for daily functioning particularly in the area of school functioning. Indeed, we found that 33% of patients in this cohort experienced school problems at the time they were evaluated. Where historically, cognitive testing is generally only thought to be indicated when there is obvious brain involvement, this study sheds light on the need for such testing in rare neuro-immunologic diseases such as TM that affect the spinal cord.

Given the cognitive problems observed in TM, educational support services to address cognitive problems in the classroom are likely to be beneficial to these affected students. Examples of such services include extended time for exams, seating near the front of the classroom to reduce distractions, specific memory strategies to enhance learning, use of lists and a planner to maximize memory for assignments and other daily activities, note-taking assistance to address fine-motor skills weaknesses, the ability to dictate responses or long writing assignments, and frequent breaks during homework or class work to address fatigue and attention difficulties.

We hope that our work helps lay the foundation for larger prospective studies examining cognitive functioning in TM and that we can learn more about the role of central nervous system (CNS) inflammation on cognition and be able to systematically help families of children with these rare disorders.

If you suspect that your son or daughter with TM or other CNS demyelinating disease may be experiencing cognitive problems (e.g., difficulty paying attention, memory problems, etc.) and/or general difficulty with school performance (e.g., learning problems, declining grades, etc.), it is recommended that you consult with your physician regarding a referral for neuropsychological testing. It may be useful to mention this recently published study as a rationale for such an evaluation.

~ Lana Harder, Assistant Professor at UT Southwestern Medical Center, Department of Psychiatry, Neurology and Neurotherapeutics

The full research article is published in the Multiple Sclerosis Journal.