Pediatric Concussion: Managing Persistent Symptoms With an Interdisciplinary Approach.

OBJECTIVE: We outline the development of a clinic that works directly with youth clients, their caregivers, and family members to help address symptoms that are persisting long after the youth sustained a concussion. Client referral characteristics are described, as well as general clinic flow and procedures. Particular emphasis is placed on a novel interdisciplinary team assessment pathway designed with input from clients and families to help provide consistent treatment plans, education, direction, and conclusions for those clients with complex psychosocial, cognitive, and physical presentations. SETTING AND PARTICIPANTS: The Persistent Concussion Clinic at Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada. CONCLUSIONS: Youth with persistent concussion symptoms have limited access to interdisciplinary clinics and supports. This article outlines the practices of a large, hospital-based interdisciplinary clinic whose model can inform clinical care pathways and practices for this underserved population. Facilitators and barriers to access are discussed and future directions for the clinic and persistent concussion care in Ontario and internationally are reviewed.

Validating Accelerometry as a Measure of Arm Movement for Children With Hemiplegic Cerebral Palsy.

BACKGROUND: For children with hemiplegic cerebral palsy (HCP), rehabilitation aims to increase movement of the affected arm. However, no validated measure objectively examines this construct in pediatric practice or daily life. OBJECTIVE: The objective of this study was to evaluate the criterion and known-groups validity of accelerometry as a measure of arm movement in children and adolescents with HCP. DESIGN: This was a prospective cross-sectional study. METHODS: Twenty-seven children and adolescents with typical development (3.4-13.9 years old) and 11 children and adolescents with HCP (4.7-14.7 years old; Manual Ability Classification System rating I or II) wore accelerometers on their wrists while engaged in 20 minutes of play, which included intermittent intervals of stillness and vigorous movement of the arms. Vector magnitude (VM) values identified the presence (VM > 2.0 counts per epoch) and absence (VM ≤ 2.0 counts per epoch) of arm movement for every 2-second epoch. Video was simultaneously recorded; each 2-second interval of footage was scored as "movement" or "no movement" for each arm. RESULTS: Agreement between accelerometry and video observation was greater than or equal to 81%, and the prevalence-adjusted and bias-adjusted κ value was greater than or equal to 0.69 for both groups of participants; these results supported the criterion validity of accelerometry. The ratio of nondominant arm movement to dominant arm movement measured by accelerometry was significantly greater in participants with typical development (mean [SD] = 0.87 [0.09]) than in participants with HCP (mean = 0.78 [0.07]) on the basis of 10 age- and sex-matched pairs; these results supported known-groups validity. LIMITATIONS: The small sample size of the group with HCP prevented the stratification of data by age. Participants with HCP had high or moderately high function of the affected arm; hence, the findings do not apply to children and adolescents with more significant hemiparesis. CONCLUSIONS: Accelerometry is a valid measure of arm movement in children with HCP and children without HCP. These findings contribute to the development of innovative upper limb assessments for children with hemiparesis.

Caring for the healthcare professional.

Purpose Hospitals must systematically support employees in innovative ways to uphold a culture of care that strengthens the system. At a leading Canadian academic pediatric rehabilitation hospital, over 90 percent of clinicians viewed Schwartz Rounds™ (SR) as a hospital priority, resulting in its formal implementation as a quality improvement initiative. The purpose of this paper is to describe how the hospital implemented SR to support the socio-emotional impact of providing care. Design/methodology/approach This quantitative descriptive study provides a snapshot of the impact of each SR through online surveys at four assessment points (SR1-SR4). A total of 571 responses were collected. Findings All four SR addressed needs of staff as 92.9-97.6 percent of attendees reported it had a positive impact, and 96.4-100 percent of attendees reported each SR was relevant. Attendees reported significantly greater communication with co-workers after each SR ( p<0.001) and more personal conversations with supervisors after SR2 and SR4 ( p<0.05) compared to non-attendees. Attending SR also increased their perspective-taking capacity across the four SR. Practical implications As evidenced in this quality improvement initiative, SR addresses staff's need for time to process the socio-emotional impacts of care and to help reduce those at risk for compassion fatigue. SR supports and manages the emotional healthcare culture, which has important implications for quality patient care. Originality/value This research details an organization's process to implement SR and highlights the importance of taking care of the care provider.

Service provision for children and young people with acquired brain injury: Practice recommendations.

BACKGROUND: Providing appropriate rehabilitation services for Acquired Brain Injury (ABI) in childhood presents a number of challenges for caregivers, health and education professionals and the young person as they develop. PRIMARY OBJECTIVE: To record the challenges and possible creative solutions generated by an international group of professionals to address the needs of children with ABI. Review of information: Recommendations were generated from children's special interest group meetings of the International Brain Injury Association (Turin, Italy, 2001; Stockholm, Sweden, 2003; Melbourne, Australia, 2005; Lisbon, Portugal, 2008) and through meetings of the International Paediatric Brain Injury Society (IPBIS), formed in 2009. Delegates participating in the workshops were representative of nations from around the world and included The Netherlands, New Zealand, Australia, the UK, Finland, Germany, South Africa, the US, Canada, Sweden, Brazil and Italy. OUTCOMES: The information presented is based on a retrospective review of those meetings and the summaries of the topics considered.

Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015.

Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.

Ethics in pharmacologic research in the child with a disability.

This article reviews the unique ethical concerns that face clinicians, researchers, and family members in the realm of research involving children and youth with childhood-onset disabilities. Presented are the contemporary legal and regulatory environments in which we work and a synopsis of relevant articles on bioethics in this sector of the scientific literature. The most important ethical themes that emerged for children with disabilities include justice in research, consent and assent, child-centered communication, child- and family-centered decision making, participation in multiple studies, and therapeutic misconception. Two publicly recorded clinical studies are profiled to illustrate common considerations and concerns that arise during our ethical review of drug studies involving children with disabilities. It is concluded that the balance of access to current research and treatments must be weighed against risk for all involved. Collaborative planning amongst those involved in the development, review, approval, conduct, and oversight of drug study protocols can lead to effective scientific inquiry within the context of core ethical principles and child- and family-centered care.

Systematic review of the clinical course, natural history, and prognosis for pediatric mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To synthesize the best available evidence on prognosis after pediatric mild traumatic brain injury (MTBI). DATA SOURCES: We searched MEDLINE, Embase, PsycINFO, CINAHL, and SPORTDiscus (2001-2012), as well as reference lists of eligible articles, and relevant systematic reviews and meta-analyses. STUDY SELECTION: Controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 MTBI pediatric cases. After 77,914 records were screened for the entire review, 299 studies were eligible and assessed for scientific rigor. DATA EXTRACTION: Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and extracted data from accepted articles into evidence tables. DATA SYNTHESIS: Evidence from 25 accepted articles was synthesized qualitatively according to SIGN criteria, and prognostic information was prioritized according to design as exploratory or confirmatory. Most studies show that postconcussion symptoms and cognitive deficits resolve over time. Limited evidence suggests that postconcussion symptoms may persist in those with lower cognitive ability and intracranial pathology on neuroimaging. Preliminary evidence suggests that the risk of epilepsy is increased for up to 10 years after MTBI; however, there is insufficient high-quality evidence at this time to support this link. CONCLUSIONS: Common post-MTBI symptoms and deficits in children are not specific to MTBI and appear to resolve with time; however, limited evidence suggests that children with intracranial pathology on imaging may experience persisting symptoms or deficits. Well-designed, long-term studies are needed to confirm these findings.

Psychosocial consequences of mild traumatic brain injury in children: results of a systematic review by the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To synthesize the best available evidence regarding psychosocial consequences of mild traumatic brain injury (MTBI) in children. DATA SOURCES: MEDLINE, Embase, CINAHL, PsycINFO, and SPORTDiscus were searched (2001-2012). Inclusion criteria included published peer-reviewed reports in English, French, Norwegian, Spanish, Swedish, and Danish. References were also identified from relevant reviews and meta-analyses, and the bibliographies of eligible articles. STUDY SELECTION: This article presents an update of a previous review with a much larger scope, of which this topic is a small subset of the questions addressed by that review. Controlled trials and cohort and case-control studies were selected according to predefined criteria. Two independent reviewers used modified Scottish Intercollegiate Guidelines Network criteria to critically appraise eligible studies. A total of 77,914 records were screened; 101 of these articles were deemed scientifically admissible, of which 6 investigated the psychosocial consequences of MTBI in children. DATA EXTRACTION: Two reviewers independently extracted data from accepted studies into evidence tables. DATA SYNTHESIS: We conducted a best-evidence synthesis by linking our conclusions to the evidence tables. Most accepted studies were exploratory rather than confirmatory. Preliminary evidence suggests that most children recover within 3 months post-MTBI. After 1 year, the prevalence of postconcussion symptoms and syndrome is similar between children with MTBI and children with orthopedic injuries. The functional status of children with MTBI improves over a 30-month follow-up period, but further research is needed to investigate the possibility that children with MTBI experience greater rates of psychiatric illness during the 3 years after their injury. CONCLUSIONS: The prognosis of MTBI is favorable in children. Most appear to recover functionally from a physical and psychological perspective. However, future research should investigate the risk for psychiatric illness.

Arts-based social skills interventions for adolescents with acquired brain injuries: five case reports.

OBJECTIVE: Previous research has demonstrated the value of arts-based programs for adolescents with childhood brain disorder to facilitate social skills and participation. The current study extends this work by examining the feasibility and effectiveness of an arts-based intervention for youth with acquired brain injuries (ABI). METHODS: A case study approach was used with four adolescent participants and one case control. A battery of quantitative measures were administered four and one week pre-intervention, one week post-intervention, as well six to eight month post-intervention. RESULTS: Improvements in pragmatic communication skills and social and participation goals were observed across intervention participants. Similar improvements were not seen with the case control participant. CONCLUSION: Results support the use of an arts-based intervention for youth with ABI to facilitate social skills and participation. Findings also highlight the need for more sensitive measures of these skills for these youth. Suggested guidelines for program implementation are provided.

Functional electrical stimulation therapy for recovery of reaching and grasping in severe chronic pediatric stroke patients.

Stroke affects 2.7 children per 100,000 annually, leaving many of them with lifelong residual impairments despite intensive rehabilitation. In the present study the authors evaluated the effectiveness of 48 hours of transcutaneous functional electrical stimulation therapy for retraining voluntary reaching and grasping in 4 severe chronic pediatric stroke participants. Participants were assessed using the Rehabilitation Engineering Laboratory Hand Function Test, Quality of Upper Extremity Skills Test, Pediatric Evaluation of Disability Inventory, and Assisting Hand Assessment. All participants improved on all measures. The average change scores on selected Rehabilitation Engineering Laboratory Hand Function Test components were 14.5 for object manipulation (P = .042), 0.78 Nm for instrumented cylinder (P = .068), and 14 for wooden blocks (P = .068) and on the grasp component of Quality of Upper Extremity Skills Test was 25.93 (P = .068). These results provide preliminary evidence that functional electrical stimulation therapy has the potential to improve upper limb function in severe chronic pediatric stroke patients.

Two case study evaluations of an arts-based social skills intervention for adolescents with childhood brain disorder.

OBJECTIVE: Arts-based programmes have been shown to be useful for individuals with disturbances in cognitive and behavioural functioning. The current case studies examined the feasibility and effectiveness of a theatre skills training programme to facilitate social skills and participation for adolescents with childhood brain disorder. METHODS: A case study approach was used with two adolescent participants. Focus groups were conducted immediately post-intervention, while a battery of quantitative measures were administered pre- and post-treatment, as well as 8 months post-treatment. RESULTS: Perceived and documented improvements in social skills and participation were observed from pre- to post-intervention and at follow-up. CONCLUSION: Results support the use of an arts-based intervention for youth with brain injuries to facilitate social skills and participation. Findings also highlight the need for more sensitive measures of these skills for youth with childhood brain disorder, who may have impaired awareness of their abilities and/or impairments in memory and language comprehension.

Protocol for a systematic review of prognosis after mild traumatic brain injury: an update of the WHO Collaborating Centre Task Force findings.

BACKGROUND: Mild traumatic brain injury (MTBI) is a major public-health concern and represents 70-90% of all treated traumatic brain injuries. The last best-evidence synthesis, conducted by the WHO Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation in 2002, found few quality studies on prognosis. The objective of this review is to update these findings. Specifically, we aim to describe the course, identify modifiable prognostic factors, determine long-term sequelae, and identify effects of interventions for MTBI. Finally, we will identify gaps in the literature, and make recommendations for future research. METHODS: The databases MEDLINE, PsychINFO, Embase, CINAHL and SPORTDiscus were systematically searched (2001 to date). The search terms included 'traumatic brain injury', 'craniocerebral trauma', 'prognosis', and 'recovery of function'. Reference lists of eligible papers were also searched. Studies were screened according to pre-defined inclusion and exclusion criteria. Inclusion criteria included original, published peer-reviewed research reports in English, French, Swedish, Norwegian, Danish and Spanish, and human participants of all ages with an accepted definition of MTBI. Exclusion criteria included publication types other than systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies; as well as cadaveric, biomechanical, and laboratory studies. All eligible papers were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers performed independent, in-depth reviews of each eligible study, and a third reviewer was consulted for disagreements. Data from accepted papers were extracted into evidence tables, and the evidence was synthesized according to the modified SIGN criteria. CONCLUSION: The results of this study form the basis for a better understanding of recovery after MTBI, and will allow development of prediction tools and recommendation of interventions, as well as informing health policy and setting a future research agenda.

Pre-school traumatic brain injury and its impact on social development at 8 years of age.

OBJECTIVE: To confirm the clinical impression that younger pre-school children (<4 years at time of injury) who are referred to a tertiary care centre for management with moderate-to-severe traumatic brain injury (TBI) have poorer social, cognitive, physical and emotional outcomes compared to older pre-schoolers (4-6 years at time of injury) and to describe the prevalence and severity of their social impairment at 8 years of age. METHODS: This is a retrospective review of pre-schoolers with moderate-to-severe TBI from 1995-2009. Their social, cognitive, physical and emotional outcomes were assessed at 8 years of age using the Mayo-Portland Adaptability Inventory-Paediatric. RESULTS: Of 130 pre-schoolers enrolled in the database who sustained a TBI < 6 years, 93 were seen at 8 years of age (57 males, 36 females). Younger pre-schoolers (n = 61, mean 2.6 years) had inferior social outcomes (p = 0.04) and cognitive abilities (p = 0.006), trended toward poorer physical outcomes (p = 0.1), with no difference for emotional outcomes (p = 0.2), compared to older pre-schoolers (n = 32, mean 5.0 years). Overall, 19/93 had normal social function, 38/93 had mild impairment, 21/93 had moderate impairment and 15/93 had severe impairment to social function. CONCLUSIONS: Children <4 years at the time of moderate-to-severe TBI have poorer social, cognitive and physical outcomes compared to older pre-schoolers.

The transition study: a look at youth and adults with cerebral palsy, spina bifida and acquired brain injury.

A group of 100 adults and 190 youth who have cerebral palsy (CP), spina bifida (SB), and acquired brain injuries from childhood (ABIc) participated in a multi-method study focused on the transition to adult health care. The results show that 95% of youth and 61% of adults were living with their parents; 23% of the youth and 55% of adults were employed; and 60% of youth and 42% of adults reported "excellent" or "very good" health. The lowest health scores were reported by adults with SB. These findings provide a starting point for examining health issues specific to youth and young adults with CP, SB, and ABIc.

Clinical use of the Mayo-Portland Adaptability Inventory in rehabilitation after paediatric acquired brain injury.

The Mayo-Portland Adaptability Inventory (MPAI; designed to be administered by clinicians) is a popular measure of disability following head injury in adults. Its acceptability, validity, and reliability were assessed for use with children. There were 335 children and adolescents (215 males, 120 females) aged between 1 and 19 years at injury (median age 9y 8mo [SD 5y]) in our sample. The test was acceptable to respondents, rapidly and easily administered, and required only small modifications. It demonstrated validity against client and parent reports of major symptoms. It demonstrated test-retest reliability within the limitations of our data and excellent interrater accord. Consequently, the MPAI is recommended for paediatric use for evaluating rehabilitation needs and therapy outcome.

Effective rehabilitation for children and adolescents with brain injury: evaluating and disseminating the evidence.

OBJECTIVE: To develop and evaluate literature reviews of the effectiveness of rehabilitation interventions for children with brain injury. DESIGN: We wrote 6 research summaries, which were evaluated by study participants. SETTING: Community. PARTICIPANTS: A convenience sample that included 18 parents of children with brain injury, 18 service providers, and 12 insurance industry representatives. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Questionnaire designed for the evaluation of printed material. RESULTS: Few articles were found that focused on evaluation of rehabilitation interventions for children with brain injury. Study participants were representative of a broad range of educational and professional backgrounds. Before reading the research summaries, service providers reported greater familiarity with the topics than did parents and insurance representatives. Despite this finding, there were no significant between-group differences in the format, content, and impact ratings provided by the 3 participant groups. CONCLUSIONS: Research summaries written in a clear, straightforward manner are appropriate for people with different educational and professional backgrounds. Further research into the effectiveness of rehabilitation interventions is needed to support informed decision-making that results in the best outcomes for children with brain injury.

Rehabilitation and ongoing support after pediatric TBI: twenty years of progress.

This article summarizes major developments of the past 20 years in both acute and chronic management of children with traumatic brain injury. The article begins with brief summaries of developments in acute and rehabilitative medical management and physical rehabilitation. Because long-term cognitive, behavioral, academic, and family issues tend to be dominant after pediatric TBI, more attention is given to these topics. The article ends with a list of general themes that have been identified as critical in providing effective long-term services and supports to children with TBI and their families.

Online support to facilitate the reintegration of students with brain injury: trials and errors.

The reintegration of students after acquired/traumatic brain injury (ABI/TBI) continues to be fraught with difficulties. Presented are (1) case studies exploring the potential of online support for teachers of students with ABI after returning from a paediatric rehabilitation centre; (2) results of Internet-based courses about reintegrating students with ABI; (3) outcomes of videoconferencing-based and Internet email-based support; (4) development of an online support process that uses Questions and Answers as a quick and immediate resource for teachers. The authors recommend that a collaborative process be instituted, in order to generate a relatively small number of high quality online resources about re-integrating students into their school and community. A second recommendation focuses on the development of online support network which may be text or email based or which may use videoconferencing over the Internet. Such networks allow students with ABI to maintain contact with their family and friends in the home community and facilitate their reintegration. An Internet-based support structure also allows professionals to provide consultation, collaboration and continuing input.