When is virtual reality "therapy"?

The use of virtual reality (VR) systems within physical rehabilitation clinical practice and research is rapidly developing, highlighting the need for consensus as to the meaning and relevance of the label "VR therapy." The purpose of this communication is to argue that explicit examination of the inferences underlying this label and discussion regarding the role of clinicians in VR implementation are required. In this vein, we propose what we consider to be a more relevant label and discuss the need for evidence to support knowledge translation initiatives for therapists interested in integrating VR systems within clinical practice.

Ecological assessment of cognitive functions in children with acquired brain injury: a systematic review.

BACKGROUND: Childhood acquired brain injury (ABI) often leads to impairment in cognitive functioning, resulting in disabilities in both the home and school environment. Assessing the impact of these cognitive deficits in everyday life using traditional neuropsychological tests has been challenging. This study systematically reviewed ecological measures of cognitive abilities available for children with ABI. METHOD: Eight databases were searched (until October 2011) for scales: (1) focused on ecological assessment of cognitive functioning; (2) with published data in an ABI population; (3) applicable to children up to 17;11 years of age; and (4) in English. The title and abstract of all papers were reviewed independently by two reviewers. RESULTS: Database searches yielded a total of 12 504 references, of which 17 scales met the inclusion criteria for the review, focusing on executive functions (n = 9), memory (n = 3), general cognitive abilities (n = 2), visuo-spatial skills (n = 2) and attention (n = 1). Four tasks used observation of actual performance in a natural environment, five were proxy-reports and six were functional paper and pencil type tasks, performed in an office. CONCLUSION: Overall, few measures were found; eight were still experimental tasks which did not provide norms. Executive functions were better represented in ecological assessment, with relatively more standardized scales available.

Restraint of children with additional needs in motor vehicles: knowledge and challenges of paediatric occupational therapists in Victoria, Australia.

AIM: This research project aimed to understand the challenges faced by occupational therapists when making recommendations regarding the restraint of children with additional needs in motor vehicles in Victoria, Australia. METHODS: A cross-sectional survey design was used to explore current practice in relation to the prescription of motor vehicle restraints in Victoria, Australia. An electronic survey was sent to occupational therapists working with children aged from birth to 18 years in early intervention services, hospitals, schools, community services or private practice. RESULTS: Challenges faced by occupational therapists related to a lack of knowledge of relevant standards and legal requirements, issues seating children with behavioural difficulties, families' inability to purchase recommended equipment and constraints as a result of funding issues. CONCLUSION: Further work is required to develop appropriate resources which support occupational therapists to make car seating recommendations for children with additional needs which comply with Australian legal requirements and standards.

Does intervention using virtual reality improve upper limb function in children with neurological impairment: a systematic review of the evidence.

BACKGROUND: Virtual reality (VR) is an emerging area of paediatric clinical and research practice, however the majority of research to date has focused on outcomes for adults following stroke. This paper appraises and describes current evidence for use of virtual reality interventions to improve upper limb function of children with neurological impairment. METHODS: A comprehensive database search was undertaken to explore literature on the use of VR systems for rehabilitation of upper limb skills of children with neurological impairment. Studies investigating the use of robotics or other mechanical devices were excluded. Five studies were found and were critiqued using the Downs and Black scale for measuring study quality. RESULTS: One randomized control trial and four case studies were found. No study scored over 50% on the Downs and Black scale, indicating methodological limitations that limit generalizability. CONCLUSIONS: Current evidence for the use of VR to improve hand and arm skills is at an emerging stage. Small sample sizes and inconsistencies in outcome measurement limit the ability to generalize findings. Further studies are required to investigate the ability to maintain gains made in VR over time and to determine whether gains transfer from the VR to real life tasks and activities.

Predictors of functional ability of Australian children with acquired brain injury following inpatient rehabilitation.

OBJECTIVE: Recently, Bedell reported data from the US on functional changes during inpatient rehabilitation for children with ABI. Similar data for Australia is not available. The aim of this study was to measure functional outcomes of children admitted to rehabilitation in Victoria, Australia and to explore predictors of outcome to contribute to international benchmarking of paediatric services. METHOD: The Pediatric Evaluation of Disability Inventory (PEDI) was administered to 72 children (aged 8 months to 16 years) within 3 days of admission to rehabilitation and again in the 3 days prior to discharge to measure functional skills in self-care, mobility and social function. Outcome data for the three domains are described and baseline and injury characteristics explored as predictors of outcome using linear regression models. RESULTS: Significant improvements in PEDI scores across all domains were demonstrated from admission to discharge. Older age at injury, higher baseline scores and being female were all predictive of better outcomes at discharge. CONCLUSIONS: Findings revealed that patterns of recovery in this sample were similar to those reported in previous studies. Continued use of the PEDI for inpatient rehabilitation is recommended to further investigate effects of injury type and the impact of therapy on outcome.

Children's participation in home, school and community life after acquired brain injury.

AIMS: This study aimed to describe participation at home, school and in the community of Australian children who had sustained an acquired brain injury (ABI). Parent ratings regarding the impact of cognitive, motor and behavioural impairments on participation were obtained. In addition, the influence of environmental factors on participation was investigated. METHODOLOGY: This study used a cross-sectional design with convenience sampling to recruit 20 children who attended a rehabilitation review clinic between September 2006 and September 2007. Participants completed the Child and Family Follow-up Survey (Bedell, 2004) to describe the participation of their children in home, school and community settings. The CFFS was developed based on the International Classification of Function, and uses parent report to measure the impact of impairments and environmental factors on children's participation in home, school and community life. RESULTS: The children were reported to have the greatest participation restrictions for structured events in the community, and social, play or leisure activities with peers either at school or in the community. Children were least restricted moving about in and around their own homes. CONCLUSIONS: This research describes difficulties encountered by Australian children with ABI in participating in community-based activities with their same aged peers. This study adds to the current literature describing patterns of participation of United States children who have sustained brain injuries, and provides useful information for Australian therapists to consider when addressing children's return to school and engagement with their peers following brain injury.

Evaluation of the Australian adaptation of the Keeping It Together (KIT-Australia) information package with carers of children with special needs.

BACKGROUND: Australian carers of children with special needs have expressed concerns about the limited availability and accessibility of suitable information resources. The 'Keeping It Together' (KIT) information package was developed and trialled in Canada and found to be effective in meeting the information needs of this population. AIM: The study aimed to evaluate the KIT-Australian Adaptation (KIT-Australia) to determine if it met its purpose of providing carers of children with special needs with strategies to access resources, organise information and communicate with others about their child. The study also aimed to determine whether additional changes were required to increase the KIT-Australia's utility. METHODS: Eighteen carers of children with special needs participated in the study. All participants had accessed services from the Royal Children's Hospital, Melbourne, Victoria. Demographic information was collected and carers were orientated to the KIT-Australia prior to using it. After eight weeks, a telephone survey interview was completed with each participant. A content analysis of qualitative and quantitative data provided the results. RESULTS: Most participants stated that they would continue to use the KIT-Australia, and would recommend it to other carers. Six key themes were identified: getting started, accessing resources, organising and storing information, communicating information about my child to others, recommendations and non-use of the KIT-Australia. CONCLUSIONS: Preliminary data from this study suggests that the KIT-Australia met its purpose of assisting carers of children with special needs, to access resources, organise information and communicate with others about their child. Participant recommendations to improve the usability of the KIT-Australia should be implemented for future editions of the resource. Further research may be required to adapt and facilitate use of the KIT-Australia in other Australian states and territories.

Family-centred outcome measurement following paediatric stroke.

BACKGROUND/AIM: Therapy programmes aim to provide services that are family-centred and address the specific needs of children. The Canadian Occupational Performance Measure (COPM) and the Perceived Efficacy and Goal Setting system (PEGS) are two measures that are available to assist in determining therapy priorities for children and their parents; however, the use of these measures has not been documented for children who have sustained a stroke. This project aimed to describe the functional concerns identified by children and their parents following paediatric stroke. METHODOLOGY: A cross-sectional design was used. A total of 26 children were recruited from a paediatric stroke outpatient clinic, and functional concerns were identified using either the COPM or the PEGS. RESULTS: Children and their parents identified similar issues. Of the 26 participants, 23 (88.5%) reported ongoing functional concerns at three months or more following stroke, whereas three participants did not identify any ongoing functional concerns. Functional concerns were grouped into categories of self-care, productivity and leisure as outlined in the Canadian Model of Occupational Performance. Concerns were identified across all functional domains by both children and their parents. CONCLUSIONS: The COPM and PEGS provided useful information about functional issues that are important to children and their parents following paediatric stroke. Use of these client-centred measures provides an opportunity to better understand the impact of paediatric stroke on children's functional abilities, and allows greater scope for service provision and planning for this group of children.

Sensory processing abilities of children who have sustained traumatic brain injuries.

OBJECTIVE: This study describes the sensory processing abilities of children ages 3-10 who sustained a moderate or severe traumatic brain injury (TBI). METHOD: We used a prospective, descriptive study design with convenience sampling of 20 children who were admitted to a pediatric neurosurgical unit. Caregivers provided information regarding their child's sensory processing abilities using the Sensory Profile (Dunn, 1999). We also collected demographic information related to the mechanism and severity of injury. Data were analyzed descriptively, and summary statistics were used to describe the Sensory Profiles of the children in comparison to normative data. RESULTS: Proportionally more children with TBI than children in the normative sample demonstrated behaviors outside of the typical range in all sections of the Sensory Profile except for oral sensory processing. CONCLUSION: These findings strongly support the need to include evaluation of sensory processing in any clinical assessment of children who have sustained TBI.

Assessing psychosocial functioning following childhood acquired brain injury: The Sydney Psychosocial Reintegration Scale for Children.

OBJECTIVE: The Sydney Psychosocial Reintegration Scale for Children (SPRS-C) assesses psychosocial functioning in children with acquired brain injury (ABI). This article aims to: (1) describe normative data for the parent-rated SPRS-C and, (2) evaluate the discriminant validity of the SPRS-C. METHODS: For Aim 1, participants were parents of typically developing children (TDC) aged 5-14 years (N = 200). For Aim 2, participants with ABI were aged 5-14 years (n = 26). A matched group of TDC was sampled from the larger normative sample to serve as a control group (n = 26). RESULTS: For Aim 1, SPRS-C scores across the 10 age-bands were in the higher ranges. Correlation coefficients of SPRS-C total score with child's age and parent occupational skill level were not statistically significant. For Aim 2, SPRS-C scores for the ABI group were significantly lower than the control group. CONCLUSIONS: These data provide a guide for clinical interpretation of the SPRS-C for measuring psychosocial functioning in children with ABI.

Ethics and shared decision-making in paediatric occupational therapy practice.

BACKGROUND: Sharing information and decisions with children and their parents is critical in pediatric rehabilitation. Although the ethical significance and clinical benefits of sharing decisions are established, approaches for implementing shared decision-making in clinical practice are still developing. AIM: To explore the ethical challenges of sharing information and decisions with one family in pediatric occupational therapy. METHOD: We used a single qualitative in-depth interview with an occupational therapist to examine the ethical dimensions of sharing decisions. RESULTS: We found that asking what was ethically at stake in the information-sharing process, highlighted how timing and style of information sharing impacts on understanding and collaboration within the therapeutic relationship. Using ethics-based questions assisted in drawing out the complexity of implementing the ideals of sharing information and decisions in pediatric practice. CONCLUSION: Reflecting on ethical dimensions of communication with families assists to identify approaches to shared decision-making in clinical practice.

A retrospective case series of pediatric spinal cord injury and disease in Victoria, Australia.

STUDY DESIGN: Retrospective case series. OBJECTIVE: This study aimed to describe the incidence and etiology of pediatric spinal cord disorders (SCD) at The Royal Children's Hospital (RCH). SUMMARY OF BACKGROUND DATA: Spinal cord disorders is rare in children, but those who sustain SCD typically require significant ongoing resources to optimize long-term outcomes. The incidence of pediatric SCD has been reported in Europe, North America, and South America; however, no previous reports are available for Australia. METHODS: A retrospective case series of consecutive admissions with SCD was identified using the International Classification of Diseases and Related Health Problems, 10th Edition, Australian Modification, diagnostic codes relating to initial onset of SCD for both traumatic and nontraumatic conditions. Potential cases admitted to RCH between January 1, 2000, and June 30, 2010, were identified and the RCH Trauma Registry was cross-checked to improve accuracy of case attainment. RESULTS: A total of 103 patients were admitted during the study period. Most patients (n = 68, 66%) had a nontraumatic SCD and were male (n = 68, 66%). Of the 68 patients who sustained nontraumatic spinal injuries, the majority (n = 40, 59%) were a result of neoplasm or transverse myelitis (n = 15, 22%) or other diseases of the spinal cord (n = 12, 18%). Thirty-five children were admitted after traumatic injury and more than half of these (n = 19, 54%) were involved in motor vehicle accidents, followed by sporting injuries (n = 8, 23%), falls from height (n = 7, 20%) and assault (n = 1, 3%). The average incidence of traumatic SCD and nontraumatic SCD during the study period was estimated at 3.8 and 6.5 per million children younger than 15 years, respectively. CONCLUSION: The incidence of pediatric SCD at RCH is lower than reports from Europe and the United States but may be comparable on a population basis. The incidence of nontraumatic pediatric SCD is approximately double that of traumatic SCD. LEVEL OF EVIDENCE: 3.

Gross and fine motor skills in children treated for acute lymphoblastic leukaemia.

OBJECTIVE: Chemotherapy treatment for acute lymphoblastic leukaemia (ALL) may disrupt motor development, with suggestions that gross and fine motor deficits are different depending on time since treatment. METHODS: Thirty-seven participants aged between 2.5 to 5 years at the time of diagnosis were assessed using the Movement Assessment Battery for Children, 2nd Edition (MABC-2) and the Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition, Short Form (BOT-2 SF), and divided into groups (i.e., months-off-treatment): (1) 0-12, (2) 13-24, and (3) 25-60 for comparison. RESULTS: MABC-2 and BOT-2 SF mean total scores fell within the average range. Twenty-six percent of the sample performed in the impaired range on the MABC-2. Group 2 had significantly lower Manual Dexterity scores than the normative population and lower BOT-2 SF scores than Group 1. CONCLUSION: Most children treated for ALL display appropriate motor skills, yet around a quarter experience general motor difficulties. Time-off-treatment did not affect the prevalence of motor impairments on any measure.

Participation of children with ABI and the relationship with discharge functional status.

AIMS: To investigate the relationship between children's functional status at discharge from inpatient rehabilitation and participation in home, school and community life following paediatric acquired brain injury (ABI). METHODS: The Child and Adolescent Scale of Participation (CASP) was mailed to 60 families of school-aged children who had sustained an ABI. Functional status data was obtained from the hospital database. Twenty-eight families participated in the study. RESULTS: No statistically significant correlations between functional status at discharge and participation levels were found. CONCLUSIONS: The lack of correlation raised questions regarding the sensitivity of the PEDI and the CASP. Therapists should consider the implication that children who perform well in functional tasks on the PEDI at discharge may not necessarily participate at age-expected levels upon return home. Environmental and child factors that hinder or support participation, such as physical infrastructure and impairments resulting from paediatric ABI, need to be considered when planning services.

Pretend play of children with acquired brain injury: an exploratory study.

OBJECTIVE: This exploratory study aimed to describe the self-initiated pretend play of three children who had sustained an acquired brain injury (ABI). No previous research was found. METHODS: Three children aged 3.0-6.0 years were recruited through purposive sampling. Pretend play ability was assessed using the Child-Initiated Pretend Play Assessment. RESULTS: Two of the three children scored below the range expected for children their age and one child scored above the range, indicating a wide range of pretend play ability for the children. None of the children could sustain their engagement in pretend play to complete the time of the assessment. CONCLUSION: Complex pretend play ability is a functional assessment of cognitive ability involving sequential planning, problem-solving, language and social understanding. Cognitive fatigue is argued to explain the children's limited ability to engage in play for the time expected for their ages. More research is required.

Exploring the leisure experiences of young people with spinal cord injury or disease.

PURPOSE: To explore the perceptions of young people with a spinal cord injury or disease (SCI/D) about their leisure participation at school, home and in the community. METHODS: The study used narrative enquiry to elicit the unique leisure stories of three participants aged 8-11 years with a SCI/D during two face-to-face, semi-structured interviews. Pictorial data about participants' interpersonal relationships were also gathered using a 'social atom' tool. RESULTS: Thematic analysis of participants' narratives produced three themes. 'Inside school leisure' and 'outside school leisure' detailed participants' lived experiences of leisure. 'A can-do approach to leisure' drew attention to the optimistic attitudes held by the participants and their active engagement in leisure despite their SCI/D. CONCLUSIONS: Clinicians, families and educators should explore the leisure preferences of young people with a SCI/D and support their participation in activities, which offer enjoyment, friendship and a sense of achievement.

Facilitating clinical decision-making about the use of virtual reality within paediatric motor rehabilitation: describing and classifying virtual reality systems.

AIM: The use of virtual reality (VR) as a therapeutic intervention to improve motor function is an emerging area of rehabilitation practice and research. This paper describes VR systems reported in research literature and proposes a classification framework that categorizes VR systems according to characteristics relevant to motor rehabilitation. METHODS: A comprehensive database search was undertaken to explore VR systems used in motor rehabilitation for children. Description of these systems, motor learning literature and expert opinion informed development of a classification framework. RESULTS: Six VR systems are included. The descriptive analysis describes each system according to 12 user, system and context variables. The classification framework identifies three features common to all VR systems. Seven categories are proposed to differentiate between systems. CONCLUSION: This paper organizes available information to facilitate clinical decision-making about VR systems and identifies areas of research to support the use of VR as a therapeutic intervention.