Defining paediatric neurorehabilitation: You cannot improve what you cannot characterize.

Neurorehabilitation is the primary therapy for neurological impairment in children, yet its potential to achieve change remains incompletely understood and probably underestimated. Understanding 'the difference neurorehabilitation can make' against a background of neurological repair and recovery as well as ongoing neurological development is an enormous challenge, exacerbated to no small extent by the lack of a 'common currency' for the description and measurement of the neurorehabilitation services a child is receiving. This review addresses attempts to parse neurorehabilitation treatment content in theoretically and mechanistically valid ways that might help address this challenge.

Reporting Completeness of Intensity-, Dose-, and Dosage-Related Items in Active Pediatric Upper Limb Neurorehabilitation Trials: A Systematic Review.

OBJECTIVE: To analyze the reporting completeness of the TIDieR items 8-12, in particular intensity, dose, and dosage, in active pediatric upper limb neurorehabilitation trials. DATA SOURCES: We searched PubMed Central, Scopus, CINAHL, OTseeker, and Web of Science for eligible publications. STUDY SELECTION: We included publications analyzing active pediatric upper limb neurorehabilitation interventions and assessed the reporting completeness of 11 items for each intervention and control group. DATA EXTRACTION: Two raters independently screened titles and abstracts and selected the publications using the RYYAN platform. We unblinded the results after the raters had completed their selection and resolved the disagreements by discussion. We used the same procedures to review the full texts. DATA SYNTHESIS: We included 52 randomized controlled trials with 65 intervention and 48 control groups. Authors did not report all 11 items in any of the study groups. The overall reporting completeness varied between 1% (intensity) to 95% (length of the intervention). The reporting completeness of the TIDieR items ranged from 2% (modifications) to 64% (when and how much). We found no significant differences in the reporting completeness between the intervention and control groups. CONCLUSIONS: Information essential for dose-response calculations is often missing in randomized controlled trials of pediatric upper limb neurorehabilitation interventions. Reporting completeness should be improved, and new measures to accurately quantify intensity should be discussed and developed.

Developing a fidelity measure of early intervention programs for children with neuromotor disorders.

AIM: To describe the development of an intervention-specific fidelity measure and its utilization and to determine whether the newly developed Sitting Together and Reaching to Play (START-Play) intervention was implemented as intended. Also, to quantify differences between START-Play and usual early intervention (uEI) services. METHOD: A fidelity measure for the START-Play intervention was developed for children with neuromotor disorders by: (1) identifying key intervention components, (2) establishing a measurement coding system, and (3) testing the reliability of instrument scores. After establishing acceptable interrater reliability, 103 intervention videos from the START-Play randomized controlled trial were coded and compared between the START-Play and uEI groups to measure five dimensions of START-Play fidelity, including adherence, dosage, quality of intervention, participant responsiveness, and program differentiation. RESULTS: Fifteen fidelity variables out of 17 had good to excellent interrater reliability evidence with intraclass correlation coefficients (ICCs) ranging from 0.77 to 0.95. The START-Play therapists met the criteria for acceptable fidelity of the intervention (rates of START-Play key component use ≥0.8; quality ratings ≥3 [on a scale of 1-4]). The START-Play and uEI groups differed significantly in rates of START-Play key component use and quality ratings. INTERPRETATION: The START-Play fidelity measure successfully quantified key components of the START-Play intervention, serving to differentiate START-Play from uEI.

Perceived Usability and Acceptability of Videoconferencing for Delivering Community-Based Rehabilitation to Individuals with Acquired Brain Injury: A Qualitative Investigation.

OBJECTIVES: There is limited research on the use of telerehabilitation platforms in service delivery for people with acquired brain injury (ABI), especially technologies that support delivery of services into the home. This qualitative study aimed to explore the perspectives of rehabilitation coordinators, individuals with ABI, and family caregivers on the usability and acceptability of videoconferencing (VC) in community-based rehabilitation. Participants' experiences and perceptions of telerehabilitation and their impressions of a particular VC system were investigated. METHODS: Guided by a theory on technology acceptance, semi-structured interviews were conducted with 30 participants from a community-based ABI service, including 13 multidisciplinary rehabilitation coordinators, 9 individuals with ABI, and 8 family caregivers. During the interview, they were shown a paper prototype of a telehealth portal for VC that was available for use. Interview transcripts were coded by two researchers and analysed thematically. RESULTS: The VC was used on average for 2% of client consultations. Four major themes depicted factors influencing the uptake of VC platforms; namely, the context or impetus for use, perceived benefits, potential problems and parameters around use, and balancing the service and user needs. Participants identified beneficial uses of VC in service delivery and strategies for promoting a positive user experience. CONCLUSIONS: Perceptions of the usability of VC to provide services in the home were largely positive; however, consideration of use on a case-by-case basis and a trial implementation was recommended to enhance successful uptake into service delivery.

Co-development of a physiotherapist-delivered physical activity intervention for adults with spinal cord injury.

STUDY DESIGNS: Cross-sectional survey, semi-structured interview, and randomized-controlled trial. OBJECTIVES: Optimal spinal cord injury (SCI)-specific PA intervention strategies appropriate for the physiotherapist setting are unknown. The purpose of this paper is to describe the rigorous co-development process of a theory-based, physiotherapist-led PA intervention for people with SCI and assess its feasibility for implementation in the rehabilitation setting. SETTING: Community. METHODS: Co-development of the intervention included (1) a review of the literature; (2) key informant interviews with people with SCI (n = 26); (3) a national online survey of physiotherapists' barriers, needs, and preferences (n = 239); (4) a review of the evidence and recommendations for the intervention from a stakeholder expert panel (n = 13); and (5) a randomized controlled trial of intervention training and its effects on implementation determinants amongst physiotherapists (n = 20). RESULTS: Almost 300 people with SCI and physiotherapists were engaged in the intervention development process. Optimal intervention delivery should be tailored and include (1) education on safety, PA guidelines, and behaviour change techniques, (2) referral to other peers, local programmes, and health professionals, and (3) adapted exercise prescriptions. Following intervention implementation training, physiotherapists demonstrated stronger tested and perceived knowledge, skills, resources, and confidence for promoting PA to people with SCI, ps < 0.05. CONCLUSIONS: This development process serves as an example methodology for using theory to co-create a leisure-time physical activity behaviour change intervention tailored for people with SCI.

The safety and feasibility of a new rehabilitation robotic exoskeleton for assisting individuals with lower extremity motor complete lesions following spinal cord injury (SCI): an observational study.

STUDY DESIGN: A pre-post observational study. OBJECTIVES: To evaluate the safety and feasibility of a new rehabilitation robotic device for assisting individuals with lower extremity motor complete lesions following spinal cord injury (SCI). SETTING: Three hospitals in Sichuan Province, China. METHODS: Individuals aged 15-75 years with an SCI between vertebrae six (T6) and lumbar 1 (L1) and complete motor paralysis participated in an exoskeletal-assisted walking (EAW) programme (2 weeks, 5 days/week, 30 min/day). Data were collected pre-, mid- (week 1) and post-intervention (week 2). RESULTS: Twenty-eight individuals (mean age = 41.3, 71% males) participated in the EAW programme. The distance walked during the 6-min walking test (6MWT) increased relative to that at baseline, during week 1 (13.0 ± 5.3 m) and week 2 (16.2 ± 5.3 m) when wearing the exoskeleton. The walking speed during the 10-m walking test (10MWT) increased from 0.039 ± 0.016 to 0.045 ± 0.016 m/s. The Hoffer walking ability grade, the Spinal Cord Independence Measure (SCIM), and the Walking Index for SCI II (WISCI II) changed after 2 weeks of EAW. No improvement in lower extremity motor score (LEMS) was observed. The rates of adverse events and serious adverse events were 21% and 4%, respectively. CONCLUSIONS: The EAW programme with the new robotic exoskeleton provided potential meaningful improvements in mobility for individuals with SCI and had few adverse events.

When technology cares for people with dementia: A critical review using neuropsychological rehabilitation as a conceptual framework.

Clinicians and researchers have become increasingly interested in the potential of technology in assisting persons with dementia (PwD). However, several issues have emerged in relation to how studies have conceptualized who the main technology user is (PwD/carer), how technology is used (as compensatory, environment modification, monitoring or retraining tool), why it is used (i.e., what impairments and/or disabilities are supported) and what variables have been considered as relevant to support engagement with technology. In this review we adopted a Neuropsychological Rehabilitation perspective to analyse 253 studies reporting on technological solutions for PwD. We analysed purposes/uses, supported impairments and disabilities and how engagement was considered. Findings showed that the most frequent purposes of technology use were compensation and monitoring, supporting orientation, sequencing complex actions and memory impairments in a wide range of activities. The few studies that addressed the issue of engagement with technology considered how the ease of use, social appropriateness, level of personalization, dynamic adaptation and carers' mediation allowed technology to adapt to PWD's and carers' preferences and performance. Conceptual and methodological tools emerged as outcomes of the analytical process, representing an important contribution to understanding the role of technologies to increase PwD's wellbeing and orient future research.

Optimizing measurement for neurobehavioural rehabilitation services: A multisite comparison study and response to UKROC.

To evaluate the efficacy of neurobehavioural rehabilitation (NbR) programmes, services should employ valid, reliable assessment tools; the ability to detect change on repeated assessment is a particular requirement. The United Kingdom Rehabilitation Outcomes Collaborative (UKROC) requires neurorehabilitation services to collect data using a standardized basket of measures, but the responsiveness and usefulness of using these in the context of NbR remains unknown. Anonymous data collected at two assessments for 123 people were examined using multiple methods to determine responsiveness of four outcome measures routinely used in NbR (HoNOS-ABI, FIM + FAM UK, MPAI-4, SASNOS). Predictive validity of two measures of rehabilitation complexity (RCS-E, SRS) regarding the extent of difference scores on these outcome measures at reassessment was also determined. All four outcome measures demonstrated responsiveness, with higher levels for SASNOS and MPAI-4 when only participants categorized as "most likely to change" at first assessment were analyzed. Predictive validity of the RCS-E and SRS in estimating the extent of change was variable. SRS was only predictive of improvement on the MPAI-4 whilst RCS-E was not predictive at all. Recommendations are made regarding ideal characteristics of NbR outcome measures, along with the need to develop measures of rehabilitation complexity specifically conceptualized for these programmes.

A pilot and feasibility study of the effectiveness of care mapping on person-centred care in neurorehabilitation settings.

Dementia care mapping for neurorehabilitation (DCM-NR) is a tool designed to increase person-centred care (PCC) in neurorehabilitation settings. This paper reports pilot and feasibility testing of a cluster-randomized controlled trial assessing the effectiveness of DCM-NR at increasing PCC. Forty-one staff members, from four neurorehabilitation wards, were cluster-randomized to receive DCM-NR (experimental group) or care as usual (control). Measures of PCC, attitudes to people with brain injury, and PCC self-efficacy were taken at baseline and follow-up. The experimental group were also interviewed about their experiences of the trial. Twenty-nine participants completed the study. Participants generally found the intervention and trial to be acceptable. PCC was significantly higher in the experimental than the control group at follow-up, despite levels of exposure to the intervention being low. PCC self-efficacy increased in the control group, but not in the experimental group, perhaps reflecting an initial reduction in perceived competence following feedback. Neither group showed a change in attitudes to people with brain injury. The findings suggest that this cluster-randomized trial design is acceptable; that DCM-NR shows promise as a tool for increasing PCC; and highlight modifications to the protocol that could increase the success and theoretical value of a future large-scale study.

An overview of outcome measures used in neuropsychological rehabilitation research on adults with acquired brain injury.

Outcome measurement is the cornerstone of evidence-based health care including neuropsychological rehabilitation. A complicating factor for outcome measurement in neuropsychological rehabilitation is the enormous number of measures available and the lack of a standard set of outcome measures. As a first step towards such a set, we reviewed intervention evaluation studies of the last 20 years to get an overview of instruments used for measuring outcome. The instruments were divided into two main categories: neuropsychological tests (International Classification of Functioning (ICF) level of functions) and other instruments (all other ICF domains). We considered the most common cognitive domains: memory, attention, executive functions, neglect, perception, apraxia, language/communication and awareness. Instruments used most for measuring outcome were neuropsychological tests (n = 215) in the domains of working memory, reaction times, neglect and aphasia. In the second category (n = 166) the multi-domain instruments were most represented. Several steps can be taken to select a standard set of outcome measures for future use. Next to evaluation of quality and feasibility of the instruments, expert opinion and consensus procedures can be applied.

Beyond current research practice: Methodological considerations in MS rehabilitation research (is designing the perfect rehabilitation trial the Holy Grail or a Gordian knot?).

Rehabilitation is an essential aspect of symptomatic and supportive treatment for people with multiple sclerosis (MS). The number of randomised controlled trials (RCTs) for rehabilitation interventions in MS has increased over the last two decades. The design, conduct and reporting quality of some of these trials could be improved. There are, however, some specific challenges that researchers face in conducting RCTs of rehabilitation interventions, which are often 'complex interventions'. This paper explores some of the challenges of undertaking robust clinical trials in rehabilitation. We focus on issues related to (1) participant selection and sample size, (2) interventions - the 'dose', content, active ingredients, targeting, fidelity of delivery and treatment adherence, (3) control groups and (4) outcomes - choosing the right type, number, timing of outcomes, and the importance of defining a primary outcome and clinically important difference between groups. We believe that by following internationally accepted RCT guidelines, by developing a critical mass of MS rehabilitation 'trialists' through international collaboration and by continuing to critique, challenge, and develop RCT designs, we can exploit the potential of RCTs to answer important questions related to the effectiveness of rehabilitation interventions.

A Systematic Critical Appraisal of Evidence-Based Clinical Practice Guidelines for the Rehabilitation of Children With Moderate or Severe Acquired Brain Injury.

OBJECTIVE: The aim of this review was to critically appraise the quality of evidence-based clinical practice guidelines (CPGs) for the rehabilitation of children with moderate or severe acquired brain injury (ABI). DATA SOURCES: A systematic search of MEDLINE, PsycINFO, Embase, CINAHL, and the Cochrane Library was conducted and an extensive website search of prominent professional rehabilitation society websites. STUDY SELECTION: CPGs were eligible for inclusion if they incorporated recommendation statements for inpatient and/or community rehabilitation for children with ABI and they were based on a systematic evidence search. DATA EXTRACTION: Methodological quality of eligible CPGs were appraised by 3 independent reviewers using the AGREE II instrument. Characteristics of eligible CPGs and strength of supporting evidence for included recommendations were extracted. DATA SYNTHESIS: Of the 9 included guidelines, 2 covered all ABIs, 5 focused specifically on traumatic brain injury, and 2 on stroke. Five of the CPGs were classified as high quality and 4 were of average quality. In general, CPGs scored better for scope and purpose, rigor of development, and clarity of presentation. They scored most poorly in applicability, involvement of target users, and procedures for updating the guidelines. Interrater reliability for the AGREE II was generally high across domains. Very few of the 445 recommendations included across the 9 CPGs were evidence based. CONCLUSIONS: Despite variability in quality of the guideline development process, the included CPGs generally provided clear descriptions of their overall objectives, scope and purpose, employed systematic methods for searching, selecting, and appraising research evidence, and produced unambiguous, clearly identifiable recommendations for children with ABI. Overall, existing CPGs focusing on rehabilitation for children with ABI are based on low-quality evidence or expert consensus. Future work should focus on addressing the limitations of most of the current CPGs, particularly related to supporting implementation and integrating stakeholder involvement.

[Integrated neurorehabilitation improves efficacy of treatment]. / Integrierte Neurorehabilitation verbessert Versorgungseffizienz.

Neurorehabilitation comprises medical and functional treatment. If patients in the post-hospital phase need acute medical interventions but these cannot be provided by the rehabilitation center, patients must be referred to suitable acute care hospitals; however, such referrals incur additional costs, are fraught with medical risks and delay further rehabilitation. We evaluated how integrating non-neurological medical specialties and a hospital unit into a neurorehabilitation center affects the rate of acute hospital referrals. The special situation in North-Rhine Westfalia, which was the last state in Germany to grant restricted hospital certification to neurorehabilitation centers, enabled a longitudinal assessment over 10 years. We analyzed the referral rate at one of the first hospitals in the state, which in addition to rehabilitation treatment (according to § 40 of the Social Security Code V, SGB V) now also provide hospital treatment (according to § 39 SGB V) and have reorganized in preparation for integrated treatment structures. In the center investigated (St. Mauritius Therapy Hospital Meerbusch) the average patient age increased between 2007 and 2017 from 69 years to 72 years and the proportion of severely ill patients on admission by 70%. Starting in 2012 integrated structures were established in a stepwise fashion with the inclusion of specialists in intensive care, cardiology and neurosurgery, extension of the diagnostic and interventional spectrum and establishment of a 24/7 emergency team with back-up from a new intensive care and mechanical ventilation unit. As a result referrals to hospitals dropped by more than 50% in all categories of disease severity despite the increase in age and morbidity. In view of the savings in costs of hospital treatment, reduced risks due to transfer and less interruption of rehabilitation, it is concluded that the efficacy of patient treatment is improved by discipline and sector integrated neurorehabilitation compared to isolated structures.

Clinical staff work sampling in a neurorehabilitation hospital and its relationship to severity of disease.

AIM: Study aimed to analyse how rehabilitation staff spends working time on specific activities in a neurorehabilitation hospital and to determine the number of direct activities received by patients with different levels of disease severity. BACKGROUND: Few studies have investigated how clinical staff spends their time on activities in rehabilitation hospitals without considering at the same time all working categories and without reporting the number of direct activities received by patients with respect to their disease severity. DESIGN: Self-reported observational study. METHOD: Work Sampling Technique was used to record direct, indirect, unit-related and personal activities every 5 min for 2 days. RESULTS: Total of 6,974 activities were recorded over 581 working hours. Physiotherapists and nurses spent 75.2% and 54.8% of their time in direct activities and medical doctors only 25.4%. Total time of direct activities was significantly different among worker categories (p = 0.001) and depended on patients' disease severity (p = 0.020) in a different manner among worker categories (interaction: p = 0.010). This time ranged from almost 4 hr up to 6½ hr for the most severely affected patients. CONCLUSION: Type of work differed among professionals. Workload greatly depended on degree of patients' disability. IMPLICATIONS FOR NURSING MANAGEMENT: Nurses and therapists spent most of their time in direct activities with patients. Economic burden of neurorehabilitation may vary greatly depending on disease severity.

A Core Set of Outcome Measures for Adults With Neurologic Conditions Undergoing Rehabilitation: A CLINICAL PRACTICE GUIDELINE.

BACKGROUND: Use of outcome measures (OMs) in adult neurologic physical therapy is essential for monitoring changes in a patient's status over time, quantifying observations and patient-reported function, enhancing communication, and increasing the efficiency of patient care. OMs also provide a mechanism to compare patient and organizational outcomes, examine intervention effectiveness, and generate new knowledge. This clinical practice guideline (CPG) examined the literature related to OMs of balance, gait, transfers, and patient-stated goals to identify a core set of OMs for use across adults with neurologic conditions and practice settings. METHODS: To determine the scope of this CPG, surveys were conducted to assess the needs and priorities of consumers and physical therapists. OMs were identified through recommendations of the Academy of Neurologic Physical Therapy's Evidence Database to Guide Effectiveness task forces. A systematic review of the literature on the OMs was conducted and additional OMs were identified; the literature search was repeated on these measures. Articles meeting the inclusion criteria were critically appraised by 2 reviewers using a modified version of the COnsensus-based Standards for the selection of health Measurement INstruments. (COSMIN) checklist. Methodological quality and the strength of statistical results were determined. To be recommended for the core set, the OMs needed to demonstrate excellent psychometric properties in high-quality studies across neurologic conditions. RESULTS/DISCUSSION: Based on survey results, the CPG focuses on OMs that have acceptable clinical utility and can be used to assess change over time in a patient's balance, gait, transfers, and patient-stated goals. Strong, level I evidence supports the use of the Berg Balance Scale to assess changes in static and dynamic sitting and standing balance and the Activities-specific Balance Confidence Scale to assess changes in balance confidence. Strong to moderate evidence supports the use of the Functional Gait Assessment to assess changes in dynamic balance while walking, the 10 meter Walk Test to assess changes in gait speed, and the 6-Minute Walk Test to assess changes in walking distance. Best practice evidence supports the use of the 5 Times Sit-to-Stand to assess sit to standing transfers. Evidence was insufficient to support use of a specific OM to assess patient-stated goals across adult neurologic conditions. Physical therapists should discuss the OM results with patients and collaboratively decide how the results should inform the plan of care. DISCLAIMER: The recommendations included in this CPG are intended as a guide for clinicians, patients, educators, and researchers to improve rehabilitation care and its impact on adults with neurologic conditions. The contents of this CPG were developed with support from the APTA and the Academy of Neurologic Physical Therapy (ANPT). The Guideline Development Group (GDG) used a rigorous review process and was able to freely express its findings and recommendations without influence from the APTA or the ANPT. The authors declare no competing interest.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A214.

The Role of Physical Activity in Recovery From Concussion in Youth: A Neuroscience Perspective.

BACKGROUND AND PURPOSE: Concussion is a major public health concern and one of the least understood neurological injuries. Children and youth are disproportionally affected by concussion, and once injured, take longer to recover. Current guidelines recommend a period of physical and cognitive rest with a gradual progressive return to activity. Although there is limited high-quality evidence (eg, randomized controlled trials) on the benefit of physical activity and exercise after concussion, most studies report a positive impact of exercise in facilitating recovery after concussion. In this article we characterize the complex and dynamic changes in the brain following concussion by reviewing recent results from neuroimaging studies and to inform physical activity participation guidelines for the management of a younger population (eg, 14-25 years of age) after concussion. SUMMARY OF KEY POINTS: Novel imaging methods and tools are providing a picture of the changes in the structure and function of the brain following concussion. These emerging results will, in the future, assist in creating objective, evidence-based pathways for clinical decision-making. Until such time, physical therapists should be aware that current neuroimaging evidence supports participation in physical activity after an initial and brief period of rest, and consider how best to incorporate exercise into rehabilitation to enhance recovery following concussion. RECOMMENDATIONS FOR CLINICAL PRACTICE: It is important that physical therapists understand the neurobiological impact of concussion injury and recovery, and be informed of the scientific rationale for the recommendations and guidelines for engagement in physical activity.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A205).

Activity and Exercise Intolerance After Concussion: Identification and Management of Postural Orthostatic Tachycardia Syndrome.

BACKGROUND AND PURPOSE: Postural orthostatic tachycardia syndrome (POTS) is increasingly recognized as a complication affecting recovery from concussion. Individuals with POTS demonstrate refractory dizziness, lightheadedness, cognitive dysfunction, fatigue, headache, chronic pain, nausea and gastrointestinal dysmotility, activity and exercise intolerance, syncope, and tachycardia. Subtypes of POTS may include hypovolemia, hyperadrenergic states, autonomic neuropathy, and underlying autoimmunity, which may variably impact response to rehabilitation in varying ways. The subtle presentation of POTS postconcussion is often mistaken for underlying anxiety, conversion disorder, or lack of motivation for recovery. This article will present clinical features of POTS that may arise after concussion, and propose a role for physical therapists in the diagnosis and management of POTS during concussion recovery. SUMMARY OF KEY POINTS: Data recorded and entered into a database during clinic visits from a large pediatric institution indicate that 11.4% of individuals diagnosed with POTS report onset of symptoms within 3 months of sustaining a concussion. Activation of the sympathetic nervous system can result in lightheadedness, shortness of breath, chest pain, tachycardia, palpitations on standing or with exertion, and activity and exercise intolerance. Identified comorbidities in people with POTS such as joint hypermobility and autoimmune disorders can further influence recovery. RECOMMENDATIONS FOR CLINICAL PRACTICE: Physical therapists may identify signs and symptoms of POTS in a subset of individuals who remain refractory to typical interventions and who exhibit symptom exacerbation with orthostatic activity. Incorporation of an individualized POTS exercise program into current established concussion interventions may be useful, with emphasis on initial recumbent exercises and ongoing physical therapy assessment of exercise tolerance for dosing of activity intensity and duration.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A211).

Effects of Timing and Intensity of Neurorehabilitation on Functional Outcome After Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

OBJECTIVE: To systematically review evidence on the effects of timing and intensity of neurorehabilitation on the functional recovery of patients with moderate to severe traumatic brain injury (TBI) and aggregate the available evidence using meta-analytic methods. DATA SOURCES: PubMed, Embase, PsycINFO, and Cochrane Database. STUDY SELECTION: Electronic databases were searched for prospective controlled clinical trials assessing the effect of timing or intensity of multidisciplinary neurorehabilitation programs on functional outcome of patients with moderate or severe TBI. A total of 5961 unique records were screened for relevance, of which 58 full-text articles were assessed for eligibility by 2 independent authors. Eleven articles were included for systematic review and meta-analysis. DATA EXTRACTION: Two independent authors performed data extraction and risk of bias analysis using the Cochrane Collaboration tool. Discrepancies between authors were resolved by consensus. DATA SYNTHESIS: Systematic review of a total of 6 randomized controlled trials, 1 quasi-randomized trial, and 4 controlled trials revealed consistent evidence for a beneficial effect of early onset neurorehabilitation in the trauma center and intensive neurorehabilitation in the rehabilitation facility on functional outcome compared with usual care. Meta-analytic quantification revealed a large-sized positive effect for early onset rehabilitation programs (d=1.02; P<.001; 95% confidence interval [CI], 0.56-1.47) and a medium-sized positive effect for intensive neurorehabilitation programs (d=.67; P<.001; 95% CI, .38-.97) compared with usual care. These effects were replicated based solely on studies with a low overall risk of bias. CONCLUSIONS: The available evidence indicates that early onset neurorehabilitation in the trauma center and more intensive neurorehabilitation in the rehabilitation facility promote functional recovery of patients with moderate to severe TBI compared with usual care. These findings support the integration of early onset and more intensive neurorehabilitation in the chain of care for patients with TBI.

Medical Safety Huddles in Rehabilitation: A Novel Patient Safety Strategy.

OBJECTIVE: To describe the implementation process, outcomes, and lessons learned in the implementation of medical safety huddles, a novel patient safety monitoring strategy that promotes physician engagement with patient safety. DESIGN: Single-center observational study. SETTING: Brain and spinal cord injury rehabilitation program at an urban, academic adult rehabilitation hospital. PARTICIPANTS: Physicians associated with the program (N=18). INTERVENTIONS: Weekly physicians' safety huddles were implemented to review, anticipate, and address patient safety issues. MAIN OUTCOME MEASURES: Main outcome measures were the number and nature of identified and anticipated patient safety incidents, actions taken, and physician attendance during huddles. The number of adverse events in the program before and after huddle implementation were secondary measures. RESULTS: Over a 7-month period, average physician attendance at medical huddles was 76.0%. There were 1.0±0.8 patient safety incidents and 3.2±2.1 anticipated patient safety issues identified in each weekly huddle. Most patient safety incidents identified were clinical administrative and clinical process related, which differed from information gathered from the organization's preexisting patient safety monitoring strategies. A total of 79 actions, or 3.3±1.8 actions per huddle, were taken in response to improve patient safety for the program. Adverse events decreased from 31.2 (95% confidence interval [CI], 27.0-35.3) to 22.9 per month (95% CI, 19.3-26.5) after implementation. CONCLUSIONS: Medical safety huddles are a novel strategy to engage physicians in patient safety and organizational quality improvement. They have the potential to enhance organizational anticipation of safety risks by supplementing existing methods. Other rehabilitation settings may wish to consider implementing and evaluating similar huddles into their existing patient safety and quality improvement frameworks.

A robot-based gait training therapy for pediatric population with cerebral palsy: goal setting, proposal and preliminary clinical implementation.

BACKGROUND: The use of robotic trainers has increased with the aim of improving gait function in patients with limitations. Nevertheless, there is an absence of studies that deeply describe detailed guidelines of how to correctly implement robot-based treatments for gait rehabilitation. This contribution proposes an accurate robot-based training program for gait rehabilitation of pediatric population with Cerebral Palsy (CP). METHODS: The program is focused on the achievement of some specifications defined by the International Classification of Functioning, Disability and Health framework, Children and Youth version (ICF-CY). It is framed on 16 non-consecutive sessions where motor control, strength and power exercises of lower limbs are performed in parallel with a postural control strategy. A clinical evaluation with four pediatric patients with CP using the CPWalker robotic platform is presented. RESULTS: The preliminary evaluation with patients with CP shows improvements in several aspects as strength (74.03 ± 40.20%), mean velocity (21.46 ± 33.79%), step length (17.95 ± 20.45%) or gait performance (e.g. 66 ± 63.54% in Gross Motor Function Measure-88 items, E and D dimensions). CONCLUSIONS: The improvements achieved in the short term show the importance of working strength and power functions meanwhile over-ground training with postural control. This research could serve as preliminary support for future clinical implementations in any robotic device. TRIAL REGISTRATION: The study was carried out with the number R-0032/12 from Local Ethical Committee of the Hospital Infantil Niño Jesús. Public trial registered on March 23, 2017: ISRCTN18254257 .